Monday 14 October
08:30

Monday 14 October

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A20
08:30 - 09:00

KEYNOTE LECTURE 1

Moderator: Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
08:30 - 09:00 Resus for the 2020s: how can we reduce the heartache of sudden death? Maaret CASTREN (Professor) (HELSINKI, FINLAND)
CONGRESS HALL
09:10

Monday 14 October

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A21
09:10 - 10:40

The Tantalising Travelling Troponin Tour: A Masterclass
Insights from the International Federation for Clinical Chemistry Committee for Cardiac Biomarkers
Cardiovascular

Moderator: Pr Rick BODY (Professor of Emergency Medicine) (Manchester, UK)
09:10 - 10:40 IFCC practice recommenations for hs-troponin. Pr Rick BODY (Professor of Emergency Medicine) (Manchester, UK), Paul COLLINSON (Consultant Chemical Pathologist) (London, UK), Allan JAFFE (Professor of Cardiology) (USA)
10:10 - 10:40 Panel discussion. Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS), Pr Edd CARLTON (Emergency Medicine Consultant) (Bristol, UK)
CONGRESS HALL

Monday 14 October

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B21
09:10 - 10:40

The Mood Zone
Workshop on resilience in the emergency department
Resilience, Wellbeing

Moderator: Senad TABAKOVIC (Zürich, SWITZERLAND)
09:10 - 10:40 "In a mad world only the mad are sane"- tips for how to stop doing Harakiri at work. Ahmed KAZMI (eusem) (London, UK)
09:10 - 10:40 How to set up a wellbeing program for your ED. Shweta GIDWANI (UK)
09:10 - 10:40 Staying Well Or At Least Drop Dead With Some Grace. Greg HENRY (USA)
FORUM HALL

Monday 14 October

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C21
09:10 - 10:40

Traumatic Cardiac Arrest
So much more than Advanced Life Support
ARRHYTHMIAS, Stroke, Trauma

Moderators: Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, GERMANY), Bernd A. LEIDEL (Vice Head) (Berlin, GERMANY)
09:10 - 10:40 Cardiac arrest following blunt trauma – no dead end. Bernd A. LEIDEL (Vice Head) (Berlin, GERMANY)
09:10 - 10:40 Thoracotomy in the prehospital field. Dr Gareth DAVIES (Speaker) (London, UK)
09:10 - 10:40 REBOA - Who and When? Dr Zaffer QASIM (Speaker) (Philadelphia, USA)
SOUTH HALL 3AB

Monday 14 October

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D21
09:10 - 10:40

YEMD - Surviving daily life in EM
Sometimes just survinig the daily struggle is a challenge
Stereotypes, Wellbeing, Young Emergency Medecine

Moderators: Dr Ross EVANS (Junior doctor) (Wolverhampton, UK), Tereza RADL (Doctor) (Prague, CZECH REPUBLIC)
09:10 - 10:40 Family compatibility & EM? What? Tereza RADL (Doctor) (Prague, CZECH REPUBLIC)
09:10 - 10:40 Everybody is a stereotype. Aleks SUSTAR (EM Resident) (Maribor, SLOVENIA)
09:10 - 10:40 Surviving mental and physical harm. Jenny GAIAWYN (Emerngency Medicine Clinical Fellow) (Truro, UK)
SOUTH HALL 3C

Monday 14 October

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E21
09:10 - 10:40

PAEDIATRICS
Paediatric Emergencies#1
HOT TOPIC SPEAKER!, Pediatric, Pulmonary, Sepsis

Moderators: Niccolò PARRI (Attending Physician) (Florence, ITALY), Pr Luigi TITOMANLIO (Head of Department) (Paris, FRANCE)
09:10 - 10:40 Fever without source in infants 0-90 days in the emergency department. Dr Roberto VELASCO (Pediatrician) (Laguna de Duero, SPAIN)
09:10 - 10:40 HOT TOPIC SPEAK! Bronchiolitis: State of the evidence based on the latest trials. Pr Franz BABL (Professor) (Melbourne, AUSTRALIA)
09:10 - 10:40 e-Health. How technologies applied to emergency medicine may help physicians? Cécile MONTEIL (FRANCE)
CHAMBER HALL

Monday 14 October

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F21
09:10 - 10:40

ABSTRACTS SESSION

Moderators: Felix LORANG (Consultant) (Jena, GERMANY), Nisanth MENON NEDUNGALAPARAMBIL (Moderator/ Faculty) (India, INDIA)
09:10 - 09:20 #18096 - OP028 Overlooked emergency – burnout syndrome among the emergency department staff.
OP028 Overlooked emergency – burnout syndrome among the emergency department staff.

Introduction: Examination of the burnout syndrome in various healthcare fields is of paramount importance for better understanding of the disorder as well as for the establishment of a suitable preventive and intervention program. The emergency departments’ employees are a risk group among healthcare workers, so it is our objective to further expand the knowledge on the characteristics of the burnout syndrome among the Hungarian emergency department staff. Aim of this study is to examine the burnout syndrome and its associations with different variables among the workers of the Department of Emergency Medicine at the University of Szeged moreover to develop and finetune a prevention and intervention training for the medical staff to help coping with everyday stress as well as rise awareness to burnout symptoms.

Method: Cross-sectioned design utilizing a self-administrated questionnaire was used to collect data from the staff (n=72). Burnout was measured using the Maslach Burnout Inventory, while psychological immune competence was measured using the Psychological Immune Competence Questionnaire. Upon data collection a three-round training was developed and implemented after which the measurement of burnout was repeated using the same test battery. We tested the interaction between different variables (age, number of children, years spent in healthcare, weekly number of working hours, number of somatic symptoms, social support and psychological immune competence) and burnout subscales (emotional exhaustion, depersonalization and personal accomplishment) using Pearson correlation. Independent samples t-test was used to compare burnout subscale means in different marital status groups, while Mann-Whitney U-test to compare burnout values between genders. Lastly, the data of the retest was compared using paired sample t-test.  

Results: We found burnout syndrome to be considerably prevalent among the workers especially nurses and physicians (compared to other staff: medical orderlies, medical clerks). Moderate emotional exhaustion was reported both among doctors and the nursing staff. While physicians reported moderate depersonalization, lower personal accomplishment was measured among the nurses. In both, original and post-training study we found a significant correlation between burnout and age, number of children, number of years in healthcare system, number of physical symptoms, social support and psychological immune system. There was no difference between genders, while the workers who were in a relationship reported significantly lower depersonalization. Due to personnel fluctuation we were able to retest only 54% of the original sample, with no change in burnout results. Nonetheless, the data shows the need for individual burnout intervention which presents in significantly stronger relationship with the psychologist as well as in frequency of contact with the psychologist.

Conclusions: The results obtained show correlations and reveal protective and risk factors in burnout which can be key to establishing a preventive and intervention strategies. The training on burnout syndrome rose awareness among the departments’ staff, while personal one to one interventions helped the workers develop individual coping strategies. This data allows us to further develop new institutional intervention techniques. Ethical approval was given by the Ethics Committee of the University of Szeged, with the license number: 122/2017-SZTE (4035).

Mona STANKOVIC (Szeged, HUNGARY), Annamária TÖREKI , Zoltán PETŐ
09:20 - 09:30 #18857 - OP029 Assessed and discharged – short-term emergency department visits.
OP029 Assessed and discharged – short-term emergency department visits.

Background

Emergency departments (EDs) play a vital role in the healthcare system either as the freely accessible primary entry point for healthcare or as secondary healthcare referred to by primary healthcare services. Recently, EDs have experienced an increased number of patients including to a greater extent elderly patients with more comorbidity. In addition, some EDs also face decreased available resources (e.g. fewer beds) and crowding in the EDs is now a reality in many countries. It is unclear how these changes affect the ED patient population. We chose to focus on the contribution of short-term ED visits to the ED population and outcome following these contacts.

Aim

Thus, our aim was to investigate 1) the proportion of short-term ED visits (5 hours or less) & 2) the characteristics, diagnoses, patterns of renewed contacts and mortality of patients with short-term ED visits.

Method

Observational cohort study of patients in the emergency departments at three sites in the North Denmark Region 2014-2016. Patients with a valid personal identification number were included. Short-term ED visits defined as 5 hours or less. Primary outcomes were ICD-10 diagnosis chapter, 1- and 30-day mortality and readmissions on days 1 and 2. Data was retrieved from the Patient Administrative System and the Danish Civil Registration System. Descriptive statistical analyses and Kaplan-Meier mortality estimates were performed.   

Results

During 2014-2016, there were 280 365 contacts to the EDs in the North Denmark Region. Of these, we included 134 362 ED visits with duration of 5 hours or less (47.9%). Mean age was 32 (IQR: 16-57), 48.6% were female.

Top five ICD-10 chapters were injury and poisoning N=80 862 (60.2%), other factors N=19 725 (14.5%), symptoms and signs N=15 568 (11.6%), musculoskeletal disease N=3 643 (2.7%) and respiratory disease N=2 413 (1.8%). Overall mortality was 1-day: 0.30% (0.27-0.33), 30-day: 0.74% (0.70-0.79), with the highest mortality among circulatory diseases: 1-day: 10.67% (9.38-12.12) 30-day: 11.94% (10.59-13.46).

Number of renewed contacts on days 1 and 2 after discharge were N=4 696 (3.5%) and N=1 652 (1.2%). ICD-10 chapter from the initial contact for patients with renewed contact on day 1: other factors N=2 522 (53.7%), injury and poisoning N=1 587 (33.8%) and symptoms and signs N=223 (4.8%) and on day 2: injury and poisoning N=951 (57.8%), other factors N=258 (15.6%) and symptoms and signs N=172 (10.4%). Overall mortality for patients with renewed contacts on day 1 or 2 was: 1-day 0.02% (0.00-0.11) and 30-day: 0.43% (0.29-0.62).

 

Discussion and conclusion

Almost half of all ED contacts were short-term visits and predominately due to injuries, which explains the young mean age and low overall mortality. Non-specific diagnoses was the second largest group of patients. Overall, only few patients had a renewed contact within 1 or 2 days. Nevertheless, patients who received non-specific diagnoses during the first admission comprised the largest group of readmitted patients on day 1.

Further research on the non-injury group of patients is needed, in particular the non-specific diagnoses.

 

 

Hassan AL-MASHAT, Tim Alex LINDSKOU, Jørgen Munkhoff MØLLER, Marc LUDWIG, Erika FRISCHKNECHT CHRISTENSEN, Dr Morten BREINHOLT SØVSØ (Aalborg, DENMARK)
09:30 - 09:40 #18354 - OP030 Applying lean methodology in the emergency department: reducing inappropriate high-sensitivity cardiac troponin I testing in patients complaining of chest pain.
OP030 Applying lean methodology in the emergency department: reducing inappropriate high-sensitivity cardiac troponin I testing in patients complaining of chest pain.

Background: chest pain is the reason for emergency department (ED) admission in 5-9% of cases. Cardiac origin has been reported in up to 45% of ED admission for chest pain. In our ED there are several predefined panels of laboratory tests that allow to improve and speed up the diagnostic process based on the prevalent symptomatology shown by the patient (for example: chest pain, abdominal pain, sepsis). In our ED we observed an increasing number of high-sensitivity cardiac troponin I (hsTnI) tests in patients complaining of chest pain. We thought that the main reason for this increase was the presence of hsTnI in the predefined chest pain test panel; furthermore, said panel didn’t differentiate between typical and atypical chest pain. The ideal management of patients experiencing chest pain includes not only avoiding misdiagnosis, but also avoiding unnecessary lab tests and therefore inappropriate hospitalizations. Based on lean methodology applied to emergency medicine, in order to further increase the quality and safety of patient care by reducing inappropriate testing, from June 2017 we decided to remove hsTnI from the predefined chest pain test panel.

Methods: we decided to conduct a retrospective, observational, monocentric study with the primary outcome of verifying whether removing hsTnI from the chest pain test panel had led to a reduction in its dosage requests over a six-month period (June-December 2018), compared to June-December 2016 in which hsTnI still appeared in the chest pain test panel. In these two periods of time we first considered the total number of patients admitted to our ED and then those who had admission and discharge diagnoses, according to the International Classification of Diseases, Tenth Edition (ICD-10), compatible with presentation of chest pain; we also considered patients with ICD-10 diagnoses not related to chest pain presentation in which hsTnI testing was requested.

Results: from June to December 2016 ED admissions were 29441 and hsTnI dosage was requested 7021 times (mean value 0.24), in the same six-months period of 2018 admissions were 30182 with 5160 hsTnI dosage requests (mean value 0.17). In 2016 and in the same six-month period cited above, patients with ICD-10 diagnosis compatible with presentation of chest pain were 1728 with 2089 hsTnI dosage requests (mean value 2.21, considering multiple tests in the same patient); in 2018 out of 1697 patients only 1752 HsTnI were requested (mean value 1.03). The same can be seen in patients with ICD-10 diagnosis not related to chest pain presentation: in 2016 out of 26307 admission hsTnI dosage was requested 4932 times (mean value 0.19), in 2018 out of 27034 admissions, hsTnI dosage was requested 3408 times (mean value 0.13).

Discussion and conclusion: the removal of hsTnI from the predefined chest pain test panel led to a decrease of inappropriate hsTnI dosage requests without causing missed diagnoses of acute coronary syndrome (ACS). Applying this kind of methodology probably forced ED physicians to better evaluate chest pain characteristics, EKG findings and patient medical history.

Roberto TARENZI, Dr Silvia PAIARDI (rozzano, ITALY), Marta PELLEGRINO, Elena CORRADA, Antonio VOZA
09:40 - 09:50 #18628 - OP031 A validation of the National Emergency Department Overcrowding Score (NEDOCS) in a UK non-specialist emergency department: a prospective observational study.
OP031 A validation of the National Emergency Department Overcrowding Score (NEDOCS) in a UK non-specialist emergency department: a prospective observational study.

Introduction 

Crowding in the Emergency Department (ED) is recognised as a significant problem linked with various adverse health outcomes.  However, there is no widely accepted measurement tool to enable clinicians to better understand and manage ED crowding, though several have been proposed including from the US the NEDOCS score.

 

Objectives

This study aimed to externally validate NEDOCS in a UK ED setting against expert clinician opinion, and to assess inter-rater reliability between nurse and consultant physician opinions.

 

Methods

This prospective single-centre study sampled data in real-time over four time periods during 2018 in a non-specialist hospital ED in the south of England to calculate NEDOCS values.  The outcome variable was clinician opinion of crowding using a six point Likert-scale for both consultant-in-charge and nurse-in-charge. Paired results were averaged to give a combined score, and dichotomised to construct AUROCs and diagnostic testing for a range of NEDOCS cut-offs.  The same method was also used to assess the association of scores with clinician opinion of risk of patient harm, safety, and adequacy of staffing levels. To adjust for the effect of temporal correlation (7), further analysis was conducted on observations sampled every six hours, offset by 2 hours for each sequential day to allow analysis of variability between and within days.

 

Results

From 905 sampled hour intervals, 448 complete data points (both clinician opinions of crowding) were obtained.  The ED was crowded 18.53% according to the composite opinion. Median NEDOCS score was 63 (IQR 43 to 85). Weighted kappa score evaluating inter-rater agreement of nurse and consultant opinion was moderate at 0.57 (95% CI: 0.56 to 0.60). AUROC for NEDOCS to predict clinical opinion of crowding was 0.81 (95% CI 0.77 to 0.86)  

For 6-hour sampling there were 157 complete observations. Adjusted for temporal correlation in this manner, AUROC was 0.80 (95% CI 0.73 to 0.88).  

For predicting clinician opinion of risk of harm and safety, AUROCs were 0.71 (95% CI 0.61 to 0.82) and 0.71 (95% CI 0.63 to 0.80) respectively. Higher scores of NEDOCS also correlated with a clinician opinion of insufficient staffing; AUROC was 0.70 (95% CI 0.64 to 0.76).

Optimal performance in our ED was a NEDOCS of >85 with a sensitivity of 59.0% (95% CI 47.7 to 69.7) and a specificity of 82.7% (95% CI 78.5 to 86.5).

Conclusions 

NEDOCS demonstrated good discriminatory power for crowding in our ED.  It also correlated with perception of safety, adequacy of staffing and risk of patient harm.  However further refinement of the score is needed, including the impact of triaged patient acuity-level, which was not incorporated in the original score.  Determining ED specific cut-off point(s) for the score is important, as the previously published thresholds for crowding may not be suitable for all EDs.  This study has demonstrated the feasibility of electronic capture in real time in a UK ED.  

Sophie SNEL (Brighton, UK), Dr Duncan HARGREAVES, Colin DEWAR, Luke HODGSON, Piervirgilio PARRELLA, Theophilus SAMUELS, Paul RODERICK
09:50 - 10:00 #18629 - OP032 An external validation of the full International Crowding Measure for the Emergency Department (ICMED) in a UK non-specialist emergency department: a prospective observational study.
OP032 An external validation of the full International Crowding Measure for the Emergency Department (ICMED) in a UK non-specialist emergency department: a prospective observational study.

Introduction 

Crowding in the Emergency Department (ED) is recognised as a significant problem linked with various adverse health outcomes.  However, there is no widely accepted measurement tool to enable clinicians to better understand and manage ED crowding, though several have been proposed including the recently derived ICMED. 

 

Objectives

This study aimed to externally validate ICMED in a different UK ED setting to the derivation studies.  Additionally the study aimed to evaluate whether using the full form of ICMED improved the score’s diagnostic ability. 

 

Methods

This prospective single-centre study sampled data in real-time over four time periods during 2018 in a UK non-specialist hospital ED to calculate ICMED values, including calculation of proportion of patients leaving the ED without being seen, the measure omitted from other studies. The outcome variable was clinician opinion of crowding using a six point Likert-scale for both consultant-in-charge and nurse-in-charge. Paired results were averaged to give a combined score, and dichotomised to construct AUROCs and diagnostic testing for a range of ICMED cut-offs.  Association of scores with clinician opinion of risk of patient harm, safety, and adequacy of staffing levels was also assessed.  To adjust for the effect of temporal correlation, further analysis was conducted on observations sampled every six hours, offset by 2 hours for each sequential day to allow analysis of variability between and within days.

 

Results

From 905 sampled hour intervals, 448 complete data points (both clinician opinions of crowding) were obtained.  The ED was crowded for 18.5% according to the composite opinion. Median ICMED score was 2 (IQR 2 to 3).  AUROC for ICMED to predict clinical opinion of crowding was 0.64 (95% CI 0.58 to 0.70). For predicting clinician opinion of risk of harm and safety, AUROCs were0.60 (95% CI 0.50 to0.70) and 0.59 (95% CI 0.49 to 0.69) respectively. Higher scores of ICMED also correlated moderately with a clinician opinion of insufficient staffing; AUROC was 0.58 (95% CI 0.52 to 0.65)

Optimal performance in our ED was an ICMED of >3 with a sensitivity of 49.4% (38.2 to 60.6) and a specificity of 74.3% (69.4 to 78.7).

For 6-hour sampling there were 157 complete observations. Adjusted for temporal correlation in this manner, AUROC was 0.69 (95% CI 0.59 to 0.79).  However, for ICMED adjustment for temporal correlation required a total of 208 complete observations and 30 crowded observation intervals for adequate power.

  

Conclusions 

This is the first study to validate the full form of the ICMED score.  ICMED demonstrated moderate discriminatory power for crowding (in line with previously published values) as well moderate discrimination for perception of safety, adequacy of staffing and risk of patient harm in our ED.  When adjusted for temporal correlation the AUROC showed a trend towards improvement.  However, the sample size was inadequate to fully account for the effect of temporal correlation.   Further data capture is currently underway to address this.  This study has demonstrated the feasibility of electronic capture of all the parameters of the ICMED score in real time in a UK ED.  

Dr Duncan HARGREAVES (Worthing, UK), Sophie SNEL, Colin DEWAR, Luke HODGSON, Piervirgilio PARRELLA, Theophilus SAMUELS, Paul RODERICK
10:00 - 10:10 #18756 - OP033 Retrospective analysis of complaints in emergency department: a quality indicator?
OP033 Retrospective analysis of complaints in emergency department: a quality indicator?

Background:

Emergency department patient complaints are often justified and may lead to apology, remedial action or compensation. The aim of the present study was to analyze emergency department patient complaints in order to identify procedures or practices that require change and to make recommendations for intervention strategies aimed at decreasing complaint rates.

Methods:

We undertook a retrospective analysis of patient complaints from a tertiary hospital emergency department from 2010 to 2018. Data were obtained from letters of response to patient’s complaints. Ethics committee of the Erasme hospital approved the study and waived informed consent.

Results:

349,714 patients were seen in the emergency room from 2010 to 2018, of whom 74,944 (21.4%) were hospitalized. In addition to this number, there are 18,206 patients (5.2%) who leave the emergency department without being seen due to department overcrowding. 279 written complaints (0.08%) were sent to the medical management of the hospital, the mediation service or directly to the emergency department. The median age of patients associated with a complaint was 33 (18-53, IQR; 0 to 80, range) years, with M:F ratio = 0.47. Among the complaints 23.5 % concerned the diagnosis, 22 % invoices for hospital care, 18 % communication with the medical doctor, 16 % the length of the waiting time, 10.5 % the treatment itself, and 10 % the nurse’s communication.

Discussion & conclusions:

Over the observation period, the yearly number of written complaints remained stable at less than 0.1 % of total number of the ED’s patients. More than 50 % of the complaints concerned a wrong or inadequate diagnosis, invoice for hospital care, and communication with the medical doctor. As a remedial measure, meticulous patient care and communication skills workshops for emergency department doctors and nurses will improve patient’s satisfaction and quality of care in the ED.

Ludovic LEFRANCQ (Mons, BELGIUM), Marc VAN NUFFELEN, Siham HBAT, Stéphane DEBAIZE, Fouzya CHIHI, Laurent LIGY, Christian MELOT
10:10 - 10:20 #18903 - OP034 Performing blood samples during Triage evaluation can improve overcrowding in ED: a Propensity-Score-Weighted Population-Based Study.
OP034 Performing blood samples during Triage evaluation can improve overcrowding in ED: a Propensity-Score-Weighted Population-Based Study.

BACKGROUND: the length of stay (LOS) in the Emergency Department (ED) is one of the causes of the overcrowding condition that currently affects most European EDs. As demonstrated in the literature, the LOS of ED patients is increasing and will increase in the coming years. A longer LOS leads to more significant crowding, poorer functioning of emergency services, increased risk of mortality and exponential cost increases. The heterogeneous morbid conditions combined with the increasing comorbidities presented by patients, force an in-depth diagnostic in many cases. It has been proved that 2/3 of patients accessing ED need an instrumental assessment and 1/3 need blood analysis. The patient's diagnostic path strongly influences the LOS.

OBJECTIVES: to verify whether sending blood samples during the triage process can decrease the LOS and the duration of the medical examination in patients with green and yellow code according to the Manchester Triage System (MTS).

METHODS: a retrospective observational study was performed from January 2018 to January 2019. All patients with a minor code (green and yellow) who needed blood sample for further diagnosis were considered. Patients who performed blood sampling during the TRIAGE evaluation were compared with those who performed blood sampling during the medical visit. Moreover, we calculated and compared the LOS and the time between the start of the medical evaluation and discharge of the two groups of patients. The anamnesis, clinical and severity characteristics documented at the time of triage were recorded.

RESULT: during the study period, 15.596 patients were enrolled. LOS was lower in the group of patients with triage blood sampling with a median of 154 minutes (100 - 231) compared to 172 (119 - 246) in the control group (p< 0.001). Overall, the triage blood sampling group was older, with greater comorbidity and with a more severe clinical condition. A propensity score matching was performed to obtain two homogeneous groups. After statistical matching, LOS remained lower in the triage-sampling group of patients (151 versus 175 minutes, p<0.001). In the adjusted multivariate model, the triage blood sample was found to be an independent factor of decrease of the LOS with standardized coefficients β = 0.857 (0.822 – 0.894, p<0.001). After propensity score matching, we also evaluated the duration of the triage, obtaining an equality of triage times both if the blood sample was taken in triage or during the medical examination, the total duration of the triage lasted 4 minutes.

CONCLUSION the execution of blood samples by the triage nurse reduces the LOS of non-urgent patients in ED and significantly reduces the duration of the medical examination.

Tania MARSONER (Merano, ITALY), Arian ZABOLI, Gianni TURCATO, Gabriele MAGNARELLI, Pasquale SOLAZZO, Eliana DUCATI, Giulia SCOLA, Annalisa FIORETTI, Norbert PFEIFER
10:20 - 10:30 #19039 - OP035 Economic value of a clinical pharmacist at the Emergency Department: a retrospective observational study.
OP035 Economic value of a clinical pharmacist at the Emergency Department: a retrospective observational study.

Background. Medication errors (MEs) and other drug related problems (DRPs) are common issues on hospital admission. These MEs and DRPs can cause preventable adverse drug events (pADEs) resulting in patient harm with a significant additional cost. A clinical pharmacist (CP) dedicated to the Emergency Department (ED) can improve medication safety by performing medication reconciliation and review, and hence avoid additional costs.

Objective. The aim of this study was to determine the economic value and the cost-benefit of a CP in the ED by applying a theoretical model (University of Sheffield School of Health and Related Research – SCHARR1).

Setting and Methods. This retrospective, single-centre, observational study was carried out in the ED of a tertiary care university hospital. Since October 2016, 1 FTE CP is dedicated to the ED. Patient-specific recommendations recorded by the CP during a 1 month period were observed. On admission to the ED, the CP had carried out a standardized medication reconciliation and medication review in order to determine pADEs. The most important pADE for each patient was selected and classified for its potential to cause harm using severity rating methods. An expert panel of senior ED physicians evaluated the pADEs for clinical significance. The net cost avoidance was calculated according to the SCHARR model1. We took into account the lower cost limit of the SCHARR model and current inflation. Statistical analysis was done using Graphpad Prism® and Microsoft Excel®.

Results. During 1 month (18 weekdays), the CP recorded recommendations for 136 patients (>18 years) admitted to the ED. On ED admission, medication reconciliation was performed for 98 patients with a median of 4 (IQR 2-7) discrepancies/patient. A medication review for both chronic medication and medication prescribed at hospital admission was performed (n=109 and n=98 respectively). Only the CP’ interventions leading to the most important pADE for each patient were taken into account for the calculation of the cost avoidance. We classified 18 (14.8%) DRPs, 66 (54.1%) DRPs, 37 (30.3%) DRPs and 1 (0.8%) DRP as a pADE with minor or no harm, significant pADE, serious pADE and at least as a severe, life-threatening or fatal pADE, respectively. According to the SCHARR model, this contributed to a net cost avoidance of €40 940. We documented 5 (4.1%) discrepancies without DRP, 53 (43.4%) discrepancies linked to a DRP and 64 (52.5%) DRPs without discrepancy with a cost avoidance of respectively €303, €17 734 and €31 003. The benefit:cost ratio was 5.05:1. Furthermore, the pharmacist carried out a total of 722 interventions.

Conclusion. A CP, integrated in a multidisciplinary ED team, has an important economic value. Furthermore, the CP enhances medication quality and safety by preventing discrepancies in the chronic medication and by the identification of DRPs on admission at the ED.

1 Campbell F, Karnon J, Czoski-Murray C, et al. A systematic review of the effectiveness and cost-effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital. Report for the National Institute for Health and Clinical Excellence as part of the Patient Safety Pilot. 2007


Saskia VAN KEMSEKE, Ellen OUDAERT (brussels, BELGIUM), Hilde COLLIER, Stephane STEURBAUT, Koen PUTMAN, Door LAUWAERT, Ives HUBLOUE
10:30 - 10:40 #19246 - OP036 Utility of a Regional Poison Center in Care of Patients Seen at Emergency Departments.
OP036 Utility of a Regional Poison Center in Care of Patients Seen at Emergency Departments.

Background:  Poison control centers (PCs) are an essential component of the healthcare system and providing clinical management and improving patient outcomes in cases of toxic exposures. PCs have also demonstrated utility in decreasing the healthcare costs by reducing the use of emergency medical services and length of stay in hospitals. Apart from the clinical expertise, PCs also provide valuable information regarding drugs including medication identification, dosage, interactions, storage, and disposal. This study analyzed the trends in exposure calls received by the PCs from emergency departments (EDs).  

Methods: The case management software, Toxicall, was queried for human exposure calls from EDs between 2016 and 2018. We descriptively assessed the relevant demographic characteristics. Trends in call frequencies and rates (per 100,000) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2016) were reported with the corresponding 95% confidence intervals (95% CI).

Results: The regional poison center serves over 2.4 million people and 45 hospitals within Southwest Virginia, with the specialists handling an average of 58,000 calls every year. Between 2016 and 2018, there were 9,767 calls that were received from the EDs, with 74% of these reporting an acute exposure to a toxic substance. Most exposures occurred at the patients’ residence (87.2%). Females (54%) were predominant in this sample. Among the cases, 23.1% were children under 6 years of age while 8.2% were individuals above 60 years of age. Unintentional reasons accounted for 47.9% cases, while suspected suicides were responsible for 36.2% calls. Ingestion (77.6%) was the most common route of exposure followed by inhalation (7.2%). Unintentional reasons accounted for majority of cases under 6 years of age, while intentional reasons caused 83% of teenage exposures. Intentional exposures were more common among the adult age groups. Serious adverse events were uncommon in our sample, with 10% cases exhibiting major clinical outcomes and only 10 fealties reported in the 3 year study period. Neurological (28.9%) and cardiovascular (19.4%) effects were most pronounced. Approximately one-fourth of the patients were admitted to the psychiatric facility. Exposures to pharmaceuticals like acetaminophen (7.6%) were frequent. Exposures to alcoholic beverages (8%) were also common. Fluids and IV were used as a therapy in 40% cases. While the frequency of calls received by the PC from EDs decreased from 3,461 in 2016 to 3,302 in 2018, the rate of such calls per 1,000 calls received by the PC increased significantly by 5.7% (95% CI: 2.3%, 8.7%, p<0.011) from 169.9 to 179.6 during the study period.     

Conclusions:  Rate of calls received by the PC from EDs during the study period increased. The PCs, a reliable source of information, are being increasingly utilized for the management of complex poisoning cases. PCs provide the EDs with immediate access to the experts who can help in the diagnosis, management, and treatment of toxic exposures and drug overdoses. This triage of cases ensures an optimal level of care leading to reductions in hospitalizations and improving the quality of healthcare.

Saumitra REGE (Charlottesville, VA, USA), Dr Christopher HOLSTEGE
TERRACE 2B
10:40 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
11:10

Monday 14 October

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A22
11:10 - 12:40

Prehospital
Changing Views Outside the ED
Pre Hospital

Moderators: Erika FRISCHKNECHT CHRISTENSEN (Professor) (DENMARK, DENMARK), Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
11:10 - 12:40 From The Fab Four to the Rolling Stones – changes in EMS-patient pattern. Erika FRISCHKNECHT CHRISTENSEN (Professor) (DENMARK, DENMARK)
11:10 - 12:40 New ethical (and other) challenges in prehospital emergency care. Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, CZECH REPUBLIC)
11:10 - 12:40 New technologies in prehospital conditions. Eric REVUE (Praticien Hospitalier Adjoint Chef de Service) (Paris, FRANCE)
CONGRESS HALL

Monday 14 October

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B22
11:10 - 12:40

True stories from the E.R.
Sharing wisdom through stories
General EM

Moderators: Katrin HRUSKA (Emergency Physician) (Stockholm, SWEDEN), Senad TABAKOVIC (Zürich, SWITZERLAND)
11:10 - 11:30 Do you want me to kill him, Doc? Greg HENRY (USA)
11:30 - 11:50 A Tale of Two Stabbings. Colin GRAHAM (Director and Professor of Emergency Medicine) (Hong Kong, HONG KONG)
11:50 - 12:10 The patients I’ve forgotten. Katrin HRUSKA (Emergency Physician) (Stockholm, SWEDEN)
12:10 - 12:30 The Wild Wild Life. Judith TINTINALLI (Professor) (Chapel Hill NC, USA)
11:30 - 12:40 Panel Discussion.
FORUM HALL

Monday 14 October

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C22
11:10 - 12:40

Cardiovascular Pros and Cons
The hottest issues in cardiovascular emergency medicine
Cardiovascular, Decision making

Moderators: Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS), Pr Rick BODY (Professor of Emergency Medicine) (Manchester, UK)
11:10 - 11:25 How do we use decision aids AND our brains? Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS)
11:25 - 11:40 Panel duscussion 1. Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS), Dr Steve SMITH (Speaker) (Minneapolis, MN, USA), Tomas VILLEN (Attending Physician) (Madrid, SPAIN)
11:40 - 11:55 Do we still need the ECG in the high-sensitivity troponin era? Dr Steve SMITH (Speaker) (Minneapolis, MN, USA)
11:55 - 12:10 Panel discussion 2. Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS), Dr Steve SMITH (Speaker) (Minneapolis, MN, USA), Tomas VILLEN (Attending Physician) (Madrid, SPAIN)
12:10 - 12:25 How can we best use point-of-care ultrasound (POCUS) to diagnose acute heart failure? Tomas VILLEN (Attending Physician) (Madrid, SPAIN)
12:25 - 12:40 Panel discussion 3. Tomas VILLEN (Attending Physician) (Madrid, SPAIN), Dr Steve SMITH (Speaker) (Minneapolis, MN, USA), Barbra BACKUS (Emergency Physician) (Leiden, THE NETHERLANDS)
SOUTH HALL 3AB

Monday 14 October

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D22
11:10 - 12:40

YEMD - Surviving a terror attack - a practical guide for YOU
A spectacular, interactive experience prepared by special forces professionals
Disaster medicine, Mass casualty, Sonography, Ultrasound, Young Emergency Medecine

Moderator: Dr Kasia HAMPTON (Emergency Department Medical Director) (USA/Poland, USA)
11:10 - 12:40 Interactive - what if YOU are under attack? Jan VINS (Prague, CZECH REPUBLIC)
11:10 - 12:40 Interactive - what if YOU are under attack? Marcus CALISSENDORFF (.....) (Sweden, SWEDEN)
11:10 - 12:40 Ultrasound for triage in mass casualty. Dr Kasia HAMPTON (Emergency Department Medical Director) (USA/Poland, USA)
SOUTH HALL 3C

Monday 14 October

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E22
11:10 - 12:40

PAEDIATRICS
Paediatric Emergencies#2
Pediatric, Resuscitation

Moderator: Pr Said HACHIMI IDRISSI (head clinic) (Ghent, BELGIUM)
11:10 - 12:40 Paediatric resuscitation: what to expect from the 2020 ERC guidelines. Patrick VAN DE VOORDE (Prof) (Ghent, BELGIUM)
11:10 - 12:40 Vital signs in the Paediatric ED: what's the score? Dr Damian ROLAND (Paediatric EM) (@damian_roland, UK)
11:10 - 12:40 Jack and Jill went up a hill. What happened after and how were they looked after. Epidemiology, nature and outcomes for children suffering major trauma. Ross FISHER (Consultant Paediatric Surgeon) (Sheffield, UK)
CHAMBER HALL

Monday 14 October

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F22
11:10 - 12:40

ABSTRACTS SESSION

Moderators: Door LAUWAERT (Manager) (BRUSSELS, BELGIUM), Gregor PROSEN (EM Consultant) (MARIBOR, SLOVENIA)
11:10 - 11:20 #18155 - OP037 Pre-hospital lactate and hospital troponin: short-term prognostic implications in the patient with a heart attack code, a observational prospective study.
OP037 Pre-hospital lactate and hospital troponin: short-term prognostic implications in the patient with a heart attack code, a observational prospective study.

Introduction: chest pain (ischemic heart disease) represents one of the leading causes of mortality, one of the most frequent causes of hospital admission, and one of the most common causes of consultation and care of Prehospital Emergency Medical Services (PhEMS).

The main objective was to evaluate the capacity of prehospital lactic acid (PLA) vs hospital troponin (HT), to predict early mortality at two days from the index event in patients with chest pain (ischemic heart disease).

Material and methods: Longitudinal prospective observational study, between April 1 and December 31, 2018. The study was developed on a reference population of 1,021,086 inhabitants, distributed in three provinces of Spain (Burgos, Salamanca and Valladolid) . All the hospitals included in the study have Intensive Care Unit (ICU) and hemodynamic service. It was considered that a patient fulfilled criteria to be included in the study if he had been attended by Advanced Life Support Units and transferred to the emergency services with a main diagnosis of chest pain (ischemic heart disease), and did not meet any exclusion criteria: under 18 years old, cardiorespiratory arrest, exitus and pregnant women.

Demographic data (age and gender) and PLA were collected during the first contact with the patient in prehospital care. To obtain the PLA values, the Accutrend Plus measuring device (Roche Diagnostics, Mannheim, Germany) was used. HT was collected in the Emergency Department at the hospital level with the cobas b 123 POC system (Roche Diagnostics, Mannheim, Germany).

The days of admission, need for ICU and / or hemodynamics and mortality data were obtained by reviewing the patient's electronic history at 30 days.

The main dependent variable was mortality from any cause in the hospital before the first two days from the index event.

The area under the curve (AUC) of the receiver operating characteristic (ROC) was calculated for each biomarker in terms of 2-day mortality, as well as the best score that offered greater sensitivity and joint specificity.

Results: a total of 258 patients were included in our study. The median age was 68 years (IQR: 58-81 years), 30.2% of them were women. The 2-day mortality was 7.4% (19 cases). 49.2% (127 cases) of patients required ICU.

The PLA obtained an AUROC for the two-day mortality of 0.918 (0.83-1, p <0.001), and the HT of 0.727 (0.59-0.85, p = 0.001). When comparing both curves, significant differences were observed (p = 0.001).

The value with the best sensitivity and specificity overall for the PLA was 4.1 mmol/L, sensitivity of 94.7% (75.4-99.1), specificity of 79.9% (74.4-84.5), positive predictive value 27.3 (18.0-39.0), negative predictive value 99.5 (97.1-99.9), Likelihood ratio (+) 4.72 (3.59-6.21), Likelihood ratio (-) 0.07 (0.01-0.45) and odds ratio 71.63 (9.33-549-97).

Conclusions: The use of PLA presents a very high AUROC in patients with chest pain (ischemic heart disease). The PLA can help PhEMS in the selection of the most appropriate hospital center, with acute cardiac care unit and hemodynamic unit, in order to reduce morbidity and mortality due to this prevalent pathology.

Dr Francisco MARTÍN-RODRÍGUEZ (Valladolid, SPAIN), Raúl LÓPEZ-IZQUIERDO, Carlos DEL POZO VEGAS, Julio C. SANTOS PASTOR, Ana B. LÓPEZ TARAZAGA, Juan F. DELGADO BENITO, María T. HERRERO DE FRUTOS, Mónica ESCRIBANO BARBERO, Ana VALDERREY MIELGO, María GERVÁS DE LA PISA, Francisco T. MARTÍNEZ FERNÁNDEZ, Arancha MORATE BENITO, María P. DELGADO BENITO, Isabel MANJÓN HERRERA, Maria Antonia UDAONDO CASCANTE, Germán FERNÁNDEZ BAYÓN, Rodrigues LEONARDO, Miguel A. CASTRO VILLAMOR
11:20 - 11:30 #18519 - OP038 Effectiveness of hypnosis for the prevention of anxiety during coronary angiography: The HypCor Study.
OP038 Effectiveness of hypnosis for the prevention of anxiety during coronary angiography: The HypCor Study.

Abstract

 

Background – Coronary angiography is the gold standard for the diagnosis of coronary artery disease. This procedure is nevertheless a source of anxiety given the inconvenience caused by its invasiveness but also due to the consequences linked to the discovery of potential diseases.

Aim - The aim of this study was to determine the effectiveness of hypnosis on reducing patient anxiety prior to coronary angiography.

Methods – A total of 169 patients with non-urgent indications of coronary angiography and no history of prior coronary angiography were randomized to a Hypnosis or Control group. Patients in the Hypnosis group underwent a hypnosis session with posthypnotic suggestions in self hypnosis, while those in the control group had a conversational interview with the hypnotherapist. The primary endpoint was the level of anxiety prior to the exam assessed by the Spielberger State-Trait Anxiety Inventory (STAI-Y A).

Results - Performing a hypnosis session did not translate into a significant decrease in anxiety prior to the procedure. The use of midazolam was lower (5% in the Hypnosis group versus 12%, p=0.05). Systolic blood pressure (SBP) was significantly lower before the examination (p = 0.01). There was no adverse effect secondary to hypnosis. There was no statistically significant difference between the 2 groups for the occurrence of complications due to the procedure.

Conclusion - In the present study, performing a hypnosis session upstream of a coronary angiography, with suggestions in self-hypnosis to be performed during the procedure, did not reduce the state anxiety measured immediately before the intervention. In contrast, a significant reduction in SBP was observed in the Hypnosis group. There appears to be a possible reduction in the prescription of anxiolytics through hypnosis, although the latter necessitates confirmation in a larger-scale study.

Nazmine GULER (Metz), François BRAUN, Sandrine WEBER, Christophe GOETZ, Khalife KHALIFE , Charles GENTILHOMME
11:30 - 11:40 #18548 - OP039 Could the YEARS algorithm be used to exclude PE during pregnancy? Data from the CT-PE-pregnancy study.
OP039 Could the YEARS algorithm be used to exclude PE during pregnancy? Data from the CT-PE-pregnancy study.

Introduction

In the recently published ARTEMIS study, the YEARS algorithm was shown to safely exclude pulmonary embolism (PE) and reduce usage of computed-tomography pulmonary angiogram (CTPA) among pregnant women with suspected PE. However, further validation is desirable prior to its implementation in clinical practice. Our aim was to externally validate the YEARS algorithm in pregnant women with suspected pulmonary embolism.

Methods

We performed a post-hoc analysis of a prospective management outcome study for PE diagnosis in pregnant women. PE was diagnosed using an algorithm that combined the revised Geneva Score, D-dimer test, bilateral lower limb compression ultrasonography and CTPA. All the items necessary to follow the YEARS algorithm were prospectively collected at the time of the study by the attending physician. The primary outcome was the rate of adjudicated symptomatic venous thromboembolic events at the 3-month follow up.

Results

Of the 395 women included in the original study, 371 were available for the present analysis. PE prevalence was 6.5%. Among the 371 women, 91 (25%) had no YEARS item, while 280 (75%) had one item or more: 14 had hemoptysis (3.8%), 55 had signs or symptoms of DVT (14.8%, of them 5 had a confirmed DVT on ultrasound) and pulmonary embolism was the most likely diagnosis for 262 patients (70.6%). When combined with D-dimer levels (<1000 ng/mL in women with zero item, and <500 ng/mL in women with ≥1 item), 77 women (21%) met the criteria for PE exclusion and would not have undergone a CTPA as per the YEARS algorithm. None of these 77 women had PE diagnosed during the initial work up or 3-month follow up. Therefore, the failure rate of the YEARS algorithm in our pregnant women population was 0/77 (95% confidence interval 0.0-3.9).

Discussions

These results confirm those from the recently published ARTEMIS prospective management study and provide additional evidence that the YEARS algorithm appears safe for pregnant women. Almost twice as many women could be spared from radiating imaging tests compared to the traditional algorithm. Given that D-dimer physiologically rises though pregnancy, the use of a higher D-dimer threshold (< 1000ng/ml) among patients with zero YEARS item could account for the higher diagnostic yield of the YEARS algorithm.

Limitations

The total number of women with a negative YEARS algorithm was small and the confidence interval around the estimation of PE prevalence in this group was wide, above the usual recommended limit for safe exclusion, precluding any definite conclusion to be drawn from the study. Also, in the CT-PE-pregnancy study, the likelihood of an alternative diagnosis (which is part of the Wells score but not of the Geneva score) had no consequence on patients’ management, which could have impacted the way physicians assessed this variable.

Conclusion

In our study, application of the YEARS algorithm would have resulted in safe exclusion of PE in 1 out of 5 pregnant women without the need for radiating tests, further supporting the use of the algorithm in this population.

Camille CUSSON-DUFOUR, Emilie LANGLOIS, Dr Thomas MOUMNEH (Angers), Antoine ELIAS, Guy MEYER, Karine LACUT, Jeannot SCHMIDT, Catherine LE GALL, Céline CHAULEUR, Frédéric GLAUSER, Helia ROBERT-EBADI, Marc RIGHINI, Grégoire LE GAL
11:40 - 11:50 #19063 - OP040 Pleuritic chest pain. Diagnosis of pulmonary embolism with lung ultrasound. US Wells Project.
OP040 Pleuritic chest pain. Diagnosis of pulmonary embolism with lung ultrasound. US Wells Project.

Background
Pleuritic chest pain is a common presentation in ED and it could sometimes be related to pleural irritation due to pulmonary infarct in pulmonary embolism (PE). Lung ultrasound (LUS) can detect pulmonary infarct, however its diagnostic accuracy for PE in a selected population presenting with pleuritic chest pain is unknown. The aim of the study is to analyze the performance of LUS in the diagnosis of PE in patients complaining of pleuritic chest pain. 

Methods

We combined individual patient data from three prospective cohort studies (one monocentric and two multicentric) involving patients evaluated for suspected PE in which LUS was performed at presentation. We extrapolated data regarding patients with and without pleuritic pain, and re-assessed the performance of LUS in the two populations for comparison.

Results

Among the 872 patients suspected of PE considered in the three studies, 217 (24.9%) presented with pleuritic chest pain and 655 (75.1%) without. Overall, 279 patients (32%) were diagnosed with PE. Pooled sensitivity of LUS in patients with and without pleuritic pain was respectively 81.5% (95%CI 70-90.1%) and 59.3% (95%CI 38.8-77.6%) (p <0.01). Specificity of LUS was similar in the two groups, respectively 95.4% (95%CI 90.7-98.1%) and 94.8% (95%CI 92.3-97.7%) (p>0.05). In patients with pleuritic pain, a diagnostic strategy combining Wells score with LUS performed better in terms of sensitivity (93%, 95%CI 80.9-98.5% vs 90.7%, 95%CI 77.9-97.4%), negative predictive value (96.2%, 95%CI 89.6-98.7% vs 93.3%, 95%CI 84.4-97.3%) and efficiency (56.7%, 95%CI 48.5-64.9% vs 42.5%, 95%CI 34.3-50.7%), than the conventional strategy based on Wells score and d-dimer.

Conclusion
In a population of patients suspected for PE, LUS for PE showed better sensitivity when applied to the subgroup complaining of pleuritic chest pain. In these patients, a diagnostic strategy based on Wells score and LUS performs better to exclude PE than the conventional rule based on clinical scoring and d-dimer.

Dr Cosimo CAVIGLIOLI (Florence, ITALY), Francesca Romana ERMINI, Chiara GIGLI, Angelika REISSIG, Alessandro BECUCCI, Peiman NAZERIAN, Giuliano DE STEFANO, Giovanni VOLPICELLI, Stefano GRIFONI
11:50 - 12:00 #19067 - OP041 Diagnostic accuracy of conventional chest radiography for acute aortic syndromes: results from ADVISED prospective multicenter study.
OP041 Diagnostic accuracy of conventional chest radiography for acute aortic syndromes: results from ADVISED prospective multicenter study.

ABSTRACT

Purpose. Guidelines recommend chest radiography (CR) in the workup of suspected acute aortic syndromes (AAS), if the pre-test clinical probability is low. However, the diagnostic impact of CR integration for rule-in and rule-out of AAS is unknown.

Methods. We performed a secondary analysis of the ADvISED multicenter study. Emergency Department (ED) outpatients were eligible if AAS was clinically suspected. Clinical probability was defined with the aortic dissection detection risk score (ADD-RS). CR was evaluated blindly by a radiologist, who judged on mediastinum enlargement (EM) and other signs.

Results. 1030 patients were analyzed, including 48 (4.7%) with AAS. The sensitivity and specificity of CR (any sign) were 54.2% (95%CI 39.2-68.6%) and 92.4% (95%CI 90.5-93.9%), with moderate inter-observer agreement between attending physician and radiologist for EM (k=0.44). CR integration increased the diagnostic accuracy over ADD-RS (AUC 0.87 vs 0.66; P<0.001). The sensitivity and specificity of a CR-integrated strategy were 68.8% (95%CI 53.6-80.9) and 76.5% (95%CI 73.7-79.1). CR-integrated rule-in (ADD-RS>1 or CR-positive) applied to 264 vs 130 patients with ADD-RS>1 alone, including 15 with AAS and 119 false positives. CR-integrated rule-out (ADD-RS≤1 and CR-negative) applied to 766 (74.4%) patients, including 15 with AAS (31.3% of cases).

Conclusions. In this observational study, CR integration with clinical probability assessment showed modest rule-in efficiency and insufficient sensitivity for conclusive rule-out. The pragmatic impact of CR on the workup of AAS appears questionable.

 

Alessandro BECUCCI (firenze, ITALY), Peiman NAZERIAN, Simona VEGLIA , Edoardo CAVIGLI, Soeiro ALEXANDRE DE MATOS , Christian MUELLER , Leidel BERND A. , Cosimo CAVIGLIOLI, Emanuele PIVETTA, Giovanni ALBANO, Stefano GRIFONI
12:00 - 12:10 #19175 - OP042 Myocardial strain as a marker of disease severity in infants with bronchiolitis, a pilot study.
OP042 Myocardial strain as a marker of disease severity in infants with bronchiolitis, a pilot study.

Introduction: Bronchiolitis is a respiratory viral infection, in most severe cases this may lead to acute respiratory failure and pulmonary hypertension (PH), although echocardiographic evidences of PH have been reported in mild cases too. PH may potentially affect cardiac function, though this has never been investigated so far.

Aim: To evaluate cardiac function in infants with bronchiolitis.

Methods: Infants with evidence of bronchiolitis were included. All cases underwent viral antigen testing on nasopharyngeal aspirates, arterial blood gas test and functional echocardiography within 24 hours from admission. Systolic and diastolic function for the left ventricle (LV) and right ventricle (RV) were assessed with longitudinal strain, as a measure of percentage of myocardial deformation. Based on existing normative data cut-off for RV and LV function were assessed. PH was defined by the presence of tricuspid regurgitation jet (TR) and septal position quantified by end-systolic eccentricity index (EI ES). Main outcomes (duration of respiratory support, DRS, and length of stay, LOS), were collected.

Results:  28 infants, of which 15 males and 13 females, age 31 ±19 days, weight 3.160 (1.960–4.010) kg. 17 and 11 patients had syncytial respiratory virus and rhinovirus infection respectively. Cases with bronchiolitis showed significantly lower values of LS for both ventricles (LV: p0.02 and RV: p0.03) compared to normative values. Among these, 12 (43%) had normal biventricular function, 10 (36%) showed LV dysfunction and 6 (21%) a biventricular dysfunction. No significant data were found for TR and EI ES. Infants with biventricular dysfunction showed a significant increase in LOS (p0.03) and DRS (p0.03) compared to those with normal function.

Conclusions: Infants with bronchiolitis may present myocardial impairment. Cardiac function may be related to disease severity and should be routinely assessed. Future studies with larger samples are needed to confirm these data. 

Anna Maria Caterina MUSOLINO, Dr Giulia Vanina CANTONE (Rome, ITALY), Braguglia ANNABELLA, Melania EVANGELISTI, Maria CLEMENTE, Elena BOCCUZZI, Maria Chiara SUPINO, Maria Pia VILLA, Anna Claudia MASSOLO
12:10 - 12:20 #19224 - OP043 A comparison among three clinical scores to identify low risk patients with non traumatic chest pain: a retrospective study.
OP043 A comparison among three clinical scores to identify low risk patients with non traumatic chest pain: a retrospective study.

Background:

In Italy, non-traumatic chest pain represents about 6% of admission to the Emergency Department (ED), but only 15-20% of these is due to acute coronary syndrome (ACS). There are many scoring systems developed to stratify patients depending on the risk of major adverse cardiac events (MACE), particularly the HEART score, the North American Chest Pain Rule (NACPR), the Not Objective Testing Rule (NOT).

The aim of this study is the comparison of these scores in order to identify patients who can be safely discharged from the ED.

Methods:

We analysed data obtained from a previous monocentric, retrospective, observational study performed in order to analyse modified Heart Score in patients admitted to ED of Policlinico Sant’Orsola in Bologna for chest pain, between January 1 and June 30, 2014.

We enrolled 1597 consecutive 18 or older aged patients for acute non-traumatic chest pain, irrespective of comorbidities, medical treatments and the onset of symptoms. Of them, 262 were excluded because of anginal equivalent without chest pain, significant ST-segment elevation, impossibility to complete the physician’s evaluation or the follow up. 191 patients were excluded because of the lack of the second troponin, necessary for NOT and NACPR. The final population is then composed by 1144 patients.

Patients were recalled within 180 days in order to register MACE.

We used Heart Score modified for the EKG criteria: two points were assigned in case of typical acute ischemia (significant ST-segment depression and T wave changes), 0 points in the case of a normal EKG or a single known anomaly without ST-T abnormalities, one point was assigned in the other cases. Instead, we used unchanged version of the NACPR and NOT.

The performance of these scores was evaluated with the estimates of sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV). We also compared the proportion of MACE in each low risk category of Heart Score, NACPR and NOT.

Results:

According to data analysis, the average age of the population is 60 ± 19. The Heart Score identified 26% (n=297) of patients in the low risk category, NACPR 9.3% (n=107) and NOT 11% (n=123). In this class of patients, all the scores showed a sensibility and an NPV of 100% for MACE, as nobody of these presented major adverse cardiac events.

Discussion & conclusion:

According to the literature, all these scores have high NPV, which reflects their capability to identify low risk patients for ACS. Instead Heart Score identified a significantly greater number of patients than the other two scores ( p<0.0001).

This likely depends on the inclusion criteria, in particular the exclusion of patients aged greater than 50 years old, who represent the majority of the ones admitted to the ED.

If these data were confirmed in new prospective studies, Heart Score would be used in clinical practice to safely discharge patients to the ED. In this way we could improve health costs and the hospital’s overcrowding.

Gabriele FARINA, Dr Eleonora TUBERTINI (Bologna, ITALY), Luca SANTI, Elena CASADEI, Giulia CESTER, Mario CAVAZZA
12:20 - 12:30 #19241 - OP044 Blood pressure in the emergency department and incident cardiovascular disease: a retrospective cohort study.
OP044 Blood pressure in the emergency department and incident cardiovascular disease: a retrospective cohort study.

Background: High blood pressure (BP) is an established risk factor for cardiovascular disease (CVD), but hypertension remains a global challenge. Prevention, diagnosis, treatment and control of hypertension needs improvement. In the emergency department (ED), BP is measured on almost every patient in order to assess patients’ condition in the short-term, and many patients have BP levels above the threshold for hypertension. It is still unknown if BP in the ED is associated with long-term prognosis or how this BPs should be handled. The purpose of this study was to explore if BP obtained in the ED is associated with incident atherosclerotic cardiovascular disease (ASCVD), myocardial infarction (MI), or stroke.

Methods: All patients who visited two university hospital EDs between 2010 to 2016 with an obtained BP in the ED were included and studied regarding incident ASCVD, MI, and stroke. Systolic BP (SBP) and diastolic BP (DBP) were obtained through EDs databases and the endpoint diagnosis from the Swedish National Patient Register and Cause of Death Register. BP was categorized based on the definition of BP and hypertension grades. Cox proportional hazard regression was used in crude and adjusted models to estimate hazard ratios (HR), confidence interval (CI) and cumulative incidence for ASCVD, MI, and stroke. Age, sex, history of hypertension, CVD and diabetes mellitus were adjusted for, in adjusted models.

Results: A total of 300,272 patients were followed for a median of 42 months (range 0-84 months). Incident ASCVD occurred in 8,914 cases (MI 4,709 events and stroke 6,700 events). BP levels above normal (SBP: >120-129 mmHg, DBP: >80-84 mmHg) had a progressively increased association with ASCVD, MI, and stroke. In the adjusted model, SBP that corresponded to hypertension grade 1, 2, and 3 had a statistically significant association with ASCVD (SBP 140-159 mmHg: HR 1.15, 95% CI 1.06-1.24, 160-179 mmHg: HR 1.35, 95% CI 1.24-1.46, ≥180 mmHg: HR 1.59, 95% CI 1.46-1.73). Similar results were observed for DBP. DBP in the high normal category (85-89 mmHg), had a statistically significant association with ASCVD (HR 1.15, 95% CI 1.06-1.25) and stroke (HR 1.17, 95% CI 1.07-1.29). In the crude model, SBP ≥180 mmHg had the strongest association with ASCVD (HR 5.50, 95% CI 5.06-5.99). Patients with no history of hypertension had a stronger association with ASCVD (SBP ≥180 mmHg: HR 2.01, 95% CI 1.75-2.32), compared to patients with a history of hypertension (SBP ≥180 mmHg: HR 1.34, 95% CI 1.20-1.49). There was a similar association with ASCVD between directly discharged (SBP ≥180 mmHg: HR 1.55, 95% CI 1.36-1.76) and admitted patients (SBP ≥180 mmHg: HR 1.74, 95% CI 1.55-1.96). The six-year cumulative incidence of ASCVD was approximately 12% for SBP ≥180 mmHg compared to 2% for normal SBP (120-129 mmHg).

Conclusions: BP in the ED is associated with incident ASCVD, MI, and stroke with a stronger association for higher BP levels. High BP recordings in EDs should not be disregarded as isolated events, but treatment should be initiated, and patients should be referred to primary care for hypertension investigation.

Pontus ORAS (Stockholm, SWEDEN), Henrike HÄBEL, Per SKOGLUND, Per SVENSSON
12:20 - 12:40 #19268 - OP045 The CARE Rule and the CARE-HEART strategy to safely reduce troponin measurement in patients presenting with chest pain.
OP045 The CARE Rule and the CARE-HEART strategy to safely reduce troponin measurement in patients presenting with chest pain.

Objectives:

Current guidelines for patients presenting to the Emergency Department (ED) with chest pain but with no ST segment Elevation Myocardial Infarction (STEMI) on ECG are mainly based on serial troponin measurements. These strategies are safe but costly and time consuming, contributing to emergency departments’ overcrowding. Our main objective was to prospectively assess the reliability of the CARE rule, corresponding to the first 4 items on the HEART score and its association with the HEART score to safely rule-out Non-STEMI without troponin measurement (CARE) or with a single baseline troponin measurement (HEART).

Methods:

Prospective observational study in six EDs. Consecutive patients with non-traumatic chest pain and no formal diagnosis after examination and ECG were included and followed for 45-days. Items allowing computation of the CARE rule and HEART score were prospectively collected by the attending physician. The main study endpoint was the 45-day rate of MACE (myocardial infarction, percutaneous coronary intervention, coronary bypass and cardiac death). Secondary endpoint was the theoretical reduction of the number of required troponin tests, computed by the difference between the actual number of troponin tests with the theoretical number of troponin test needed if the CARE-HEART strategy would have been applied. The procedure would be deemed reliable if, when negative, the rate of MACE is <1% with an upper limit of the 95% confidence interval (95% CI) <3%.

Results:

From 1452 patients included, 1402 were analysed, 1285 had at least one troponin measurement and 97 (7%) had MACE during the follow-up. The CARE rule was negative for 279 (20%) patients and one presented a MACE: 0.4% (1/279, 95% CI: 0-2.0%). The CARE-HEART strategy was negative for an additional 476 patients (34%) and one of them had a MACE: 0.3% (2/755, 95% CI: 0-0.9%). The CARE-HEART strategy could theoretically have spared 360 troponin measurements (19%).

Discussions:

The CARE rule safely classified 20% of patients in a very-low risk category, for whom the hypothesis of a NSTEMI would have been ruled-out without the need for a troponin test. An additional 34% patients were safely classified in the low risk group according to the HEART score, on the basis of a single troponin test.

Limitations:

This was an observational study. Physicians were not aware of the strategy interpretation and they may have a different and more prudent assessment of CARE items if they were asked to apply the rule. The reduction in terms of troponin tests is theoretical and likely overestimated. Nevertheless, this testifies to the potential medico-economic benefit of the procedure.

Conclusions:

With a very low risk of MACE during follow-up, the CARE Rule and the CARE-HEART strategy may safely allow reduction of troponin measurements in patients presenting to the Emergency Department with chest pain.

Dr Thomas MOUMNEH (Angers), Andréa PENALOZA, Anda CISMAS, Sandrine CHARPENTIER, Thibault SCHOTTÉ, Sabrina PERNET, Stephanie MALATEST, Fabrice PRUNIER, Alexandra WARNANT, Tin-Hinan MEZDAD, Cédric GANGLOFF, Louis SOULAT, Delphine DOUILLET, Jérémie RIOU, Pierre-Marie ROY
TERRACE 2B
12:40 LUNCH BREAK AND EXHIBITION
14:10

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A23
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Resuscitation
Evidence-based cardiac arrest management, guided by a simulated case
Resuscitation

Moderators: Wilhelm BEHRINGER (Director) (Jena, GERMANY), Maaret CASTREN (Professor) (HELSINKI, FINLAND)
Animators: Tomas JEZEK (head of education and training center) (Hradec Králové, CZECH REPUBLIC), Dr Jiri NOVY (consultant) (Jičín, CZECH REPUBLIC), Dr Anatolij TRUHLAR (Medical Director EMS) (Hradec Kralove, CZECH REPUBLIC)
14:20 - 14:35 Intubation - Airway (AIRWAY II). Dr Lars ANDERSEN (Associate Professor) (Aarhus, DENMARK)
14:40 - 14:55 Epinephrine (PARAMEDIC II). Mathias HOLMBERG (Medical Doctor) (Aarhus, DENMARK)
15:00 - 15:15 Postresuscitation Care. Wilhelm BEHRINGER (Director) (Jena, GERMANY)
CONGRESS HALL

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B23
14:10 - 15:40

Court Room
You don't want to be part of this in real life
Human factors, Management, Medicolegal

14:10 - 15:40 4 Cases. Greg HENRY (USA), Dr John HEYWORTH (Consultant) (Southampton, UK), Dr Susie HEWITT (Consultant) (Derby, UK), Bernard FOEX (Consultant in Emergency Medicine and Critical Care) (Manchester, UK)
FORUM HALL

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C23
14:10 - 15:40

The Heart of the Matter
The one man show!
ARRHYTHMIAS, Stroke, Cardiovascular, HOT TOPIC SPEAKER!

Moderator: Pr Rick BODY (Professor of Emergency Medicine) (Manchester, UK)
14:10 - 15:10 HOT TOPIC SPEAK! Subtle ECG Findings of LAD Occlusion Myocardial Infarction. Dr Steve SMITH (Speaker) (Minneapolis, MN, USA)
15:10 - 15:40 Challenge Steve Smith! Dr Steve SMITH (Speaker) (Minneapolis, MN, USA)
SOUTH HALL 3AB

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D23
14:10 - 15:40

YEMD - Unique circumstances, challenge accepted
Listen to unique stories from unique people
Conflict, Disaster medicine, International EM, MSF, Young Emergency Medecine

Moderators: Wilma BERGSTRÖM (Nurse, medical student) (Berlin, GERMANY), Youri YORDANOV (Médecin) (Paris, FRANCE)
14:10 - 15:40 From Peking to Paris. Tom ROBERTS (Doctor) (Bristol, UK)
14:10 - 15:40 In the midst of Paris during the attacks. Youri YORDANOV (Médecin) (Paris, FRANCE)
14:10 - 15:40 EM in a conflict zone (Congo). Dr Steven VAN DEN BROUCKE (Internal Medicine) (Kortrijk-Dutsel, BELGIUM)
SOUTH HALL 3C

Monday 14 October

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E23
14:10 - 15:40

PAEDIATRICS
Research in PEM - Best PEM abstract AWARD
INTERACTIVE SESSION, Pediatric, Research

Moderators: Silvia BRESSAN (Moderator) (Padova, ITALY), Rianne OOSTENBRINK (pediatrician) (Rotterdam, THE NETHERLANDS)

14:10 - 14:40 Fast track in PEM. Rianne OOSTENBRINK (pediatrician) (Rotterdam, THE NETHERLANDS), Dr Ruud NIJMAN (academic clinical lecturer) (London, UK)
14:40 - 15:10 PSA in the ED. Cyril SAHYOUN (Attending Physician / Médecin adjoint du chef de service) (Geneva, SWITZERLAND), Silvia BRESSAN (Moderator) (Padova, ITALY)
15:10 - 15:20 #18296 - OP118 A NICE combination predicting hospitalisation at triage: a European multicentre prospective observational study of febrile children presenting to the Emergency Department.
OP118 A NICE combination predicting hospitalisation at triage: a European multicentre prospective observational study of febrile children presenting to the Emergency Department.

Background and aims:

A large proportion of paediatric Emergency Department (ED) visits consists of febrile children. A prolonged process between arrival at the ED and hospital admission can negatively influence ED crowding and subsequent quality of care for the individual patient. 

While several studies have focused on predicting hospital admission, many of those either focused on adults, on specific diseases (e.g. asthma only) or were performed in a single setting, thus limiting the generalizability of the result to other settings with a different case mix and different admission rates. Furthermore, many models included variables that were not available at triage, such as laboratory results.

We aimed to investigate early risk factors for hospital admission in febrile children attending different EDs in Europe, and to develop and validate a prediction model identifying those children needing hospitalisation, thereby improving patient flow and quality of care.

 

Methods:

In the MOFICHE study (Management and Outcome of Fever in children in Europe, January 2017-April 2018) data were collected on febrile children aged 0–18 years presenting to 12 European. MOFICHE is part of the PERFORM study (http://www.perform2020.eu). Routine data were prospectively collected and included general patient characteristics, markers of disease severity (abnormal vital signs according to the APLS reference ranges, Paediatric Early Warning Score (PEWS) and NICE fever guideline red alarming signs) and disposition (discharge, admission, ICU admission). 
A prediction model for hospitalisation was constructed using multivariable logistic regression analysis. We used a stepwise approach in which models with general patient characteristics, vital signs, PEWS and NICE alarming signs were tested separately, and were subsequently combined in the final model. The prediction model was derived in a random sample of half of the cases and validated in the remaining set. We determined the discriminative value of the model by calculating the receiver operating curves (ROCs) and assessed the predictive performance (sensitivity, specificity) at a high specificity level as our aim was to identify children at high risk for admission. 

 

Results:

38,496 children were included. Of those, 13.397 (34,9%) children were admitted to a general ward and 156 to the ICU. 
When testing patient characteristics and markers of disease severity separately, only the NICE alarming signs performed well with an AUC of 0.77 (95% CI 0.77-0.77), while patient characteristics, vital signs and PEWS performed poorly (AUC’s all below <0.70). 

However, combining patient characteristics, vital signs and NICE alarming signs yielded an AUC of 0.82 (95% CI 0.82-0.82). The model performed equally well in the validation set.
A “rule-in model” was created, which was highly specific (95%) with low sensitivity (37%), a positive likelihood ratio of 7.5 and a positive predictive value of 72%.

A digital calculator was constructed to facilitate clinical use.

 

Conclusion:

The combination of patient characteristics and markers of disease severity available at triage can be used to identify children at high risk for hospitalisation at an early stage and improve ED patient flow.

Dorine BORENSZTAJN (Rotterdam, THE NETHERLANDS), Nienke HAGEDOORN, Ulrich VON BOTH, Enitan D. CARROL, Manuel DEWEZ, Marieke EMONTS, Michiel VAN DER FLIER, Ronald DE GROOT, Jethro HERBERG, Benno KOHLMAIER, Emma LIM, Ian MACONOCHIE, , Federico MARTINON-TORRES, Ruud NIJMAN, Marko POKORN, Franc STRLE, Maria TSOLIA, Clementien VERMONT , Shunmay YEUNG, Dace ZAVADSKA, Werner ZENZ, Michael LEVIN, Henriëtte A MOLL
15:20 - 15:30 #18493 - OP119 A randomised, double-blind, placebo controlled trial of ondansetron to reduce vomiting in children receiving intranasal fentanyl and nitrous oxide for procedural sedation and analgesia.
OP119 A randomised, double-blind, placebo controlled trial of ondansetron to reduce vomiting in children receiving intranasal fentanyl and nitrous oxide for procedural sedation and analgesia.

Background:

Intranasal fentanyl and nitrous oxide are frequently combined for procedural sedation and analgesia in children. This approach is advantageous for its non-parenteral administration, but is associated with a higher incidence of vomiting than nitrous nitrous used as a sole agent. We sought to assess whether the preprocedural use of ondansetron reduces the incidence of vomiting associated with the combination of intranasal fentanyl and nitrous oxide for procedural sedation compared with placebo.

 Methods:

This was a double-blind, randomised, placebo controlled superiority trial conducted between October 2016 and January 2019 at a single tertiary care paediatric emergency department. Eligible patients were children aged 3-18 years with planned sedation with intranasal fentanyl and nitrous oxide. Participants were randomised to receive ondansetron or placebo 30-60 minutes prior to nitrous oxide administration. The primary outcome was early vomiting associated with procedural sedation defined as occuring during or up to 1 hour after nitrous oxide administration. Secondary outcomes were: number of vomits and retching during procedural sedation, vomiting 1 to 24 hours post procedural sedation, procedural sedation duration, adverse events and quality of sedation across the two groups.

 

Results:

442 participants were randomised and outcome data were available for analysis in 436 participants. There was little evidence of a difference in the primary outcome, early vomiting associated with procedural sedation, between the groups: ondansetron 12% vs. placebo 16%, difference in proportions -4.6% (95% confidence interval [CI] -11 to 2.0; P=.18). However, the overall vomiting incidence up to 24 hours after the procedure was lower in ondansetron treated patients 21% vs. placebo 31% (-10%, 95%CI -19 to -1.4; P=.02), number needed to treat of 10. All other secondary outcomes were similar between the groups. Most sedations were reported as optimal by the treating clinician (91%). There were only two minor adverse events, both in the placebo group. There were no serious adverse events.

 

Discussion & Conclusions:

This is the first study reporting on premedication to prevent vomiting associated with the combination of intranasal fentanyl and nitrous oxide for procedural sedation in children. In this trial, the incidence of early vomiting was lower than previously reported in the literature, which may explain our null findings. We found little evidence that ondansetron reduces the incidence of early vomiting related to procedural sedation with the combination of intranasal fentanyl and nitrous oxide. This trial adds further evidence regarding safety of this sedation strategy.

Emmanuelle FAUTEUX-LAMARRE, Pr Franz E BABL (Melbourne, AUSTRALIA), Michelle MCCARTHY, Nuala QUINN, Andrew DAVIDSON, Donna LEGGE, Katherine J LEE, Greta M PALMER, Sandy M HOPPER
15:30 - 15:40 #18769 - OP120 Clinical prediction to target new biomarkers in febrile children at the ED, a European observational study.
OP120 Clinical prediction to target new biomarkers in febrile children at the ED, a European observational study.

Background: Early detection and treatment of invasive bacterial infections reduces morbidity and mortality. Distinguishing between invasive bacterial and self-limiting viral infections solely based on clinical signs and symptoms is unreliable. Therefore, overtreatment with antibiotics in febrile illnesses is common. In Europe, antibiotic prescription rates for febrile illness vary from 19% to 64%.

Aim: To externally validate and update a clinical prediction model to identify invasive bacterial infections and define risk thresholds where new biomarkers could improve accurate diagnosis.

Methods: Data of febrile children <18 years attending 12 European EDs were collected between January 2017-April 2018. The main outcome measure was invasive bacterial infection (IBI) defined as bacteremia, sepsis or bacterial meningitis. For this analysis, we excluded children without C-reactive protein (CRP) measurement and children with urinary tract infection. We externally validated and updated an existing clinical prediction model (Feverkidstool which includes vital signs, clinical symptoms and CRP) and extended the model by including level of consciousness. We determined the discriminative value by the C-statistic and assessed the predictive performance (sensitivity, specificity, negative and positive likelihood ratios) at different thresholds.

Results: 16,225 patients were included (median age 2.8 years (IQR 1.4-6.0), 29% ill appearing) of whom 155 had an IBI. The discriminative ability of IBI versus no IBI was moderate for the original model (0.73 (95% CI 0.69-0.77) and improved in the updated model with consciousness (0.79 (95% CI 0.75-0.83). The updated model for IBI performed well for the low-risk threshold of 2.5% (sensitivity 0.93 (95% CI 0.86-0.97), negative likelihood ratio 0.39 (95% CI 0.2-0.8)) and was moderate for the high-risk threshold of 30% (specificity 0.88 (95 % CI 0.87-0.89), positive likelihood ratio 3.5 (95% CI 2.7-4.6). The intermediate thresholds of 5-30% performed poorly (ranges: sensitivity 0.58-0.85, negative likelihood ratio 0.46-0.59, specificity 0.33-0.71, positive likelihood ratio 1.26-1.99).

Conclusion: The low-risk threshold of the updated clinical prediction model is useful to rule- out patients with IBI at the ED. The intermediate and high-risk thresholds are lacking excellent rule-in value for IBI to target treatment. The number of unnecessary treated patients could potentially be reduced by addition of other new sensitive biomarkers.

Nienke HAGEDOORN (Rotterdam, THE NETHERLANDS), Dorine BORENSZTAJN, Ian MACONOCHIE, Ruud NIJMAN, Federico MARTINON-TORRES, Jethro HERBERG, Enitan CARROL, Emma LIM, Maria TSOLIA, Marieke EMONTS, Ronald DE GROOT, Michiel VAN DER FLIER, Werner ZENZ, Benno KOHLMAIER, Franc STRLE, Marko POKORN, Dace ZAVADSKA, Ulrich VON BOTH, Clementien VERMONT, Shunmay YEUNG, Michael LEVIN, Henriëtte MOLL
15:10 - 15:40 Best PEM abstract AWARD.
CHAMBER HALL

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ABSTRACTS SESSION

Moderators: Marco BONSANO (YEMD Secretary) (London, UK), Christoph DODT (ead of the Department) (München, GERMANY)
14:10 - 14:20 #19093 - OP046 The impact of dispatcher assistance in the rates and efficacy of bystander cardiopulmonary resuscitation: A meta-analysis.
OP046 The impact of dispatcher assistance in the rates and efficacy of bystander cardiopulmonary resuscitation: A meta-analysis.

Objectives The introduction and development of the concept of emergency medical services (EMS) has played a crucial role in decreasing mortality rates and returning to independent survival in out-of-hospital cardiac arrests(OHCA). The role of Dispatcher Assisted Cardiopulmonary Resuscitation (DACPR) has not been widely reported. The objectives of the study were to perform a meta-analysis of observational studies addressing whether DACPR, compared with independent Bystander Cardiopulmonary Resuscitation (BCPR),increased the rates of BCPR, and whether they altered survival outcomes compared with no BCPR in OHCA.

Methods We searched the relevant literature from PubMed and Cochrane databases. The basic information and outcome data (BCPR rates, survival to hospital discharge, 1-month survival) were extracted from the included studies. Meta-analyses were performed by using STATA 11.0 software.

Results Eight studies involving 65,148 patients were eligible. Overall meta-analysis showed that DACPR was associated with statistically improved rates of BCPR (Odds Ratio [OR] =3.48, 95% confidence interval[CI]: 2.08-5.83, I2= 96.7%), and survival to discharge/ 1-month survival (OR=1.51, 95%CI: 1.40-1.63, I2= 24.9%) when compared with no BCPR.However, no significant effect of DACPR in survival rate was found, when compared with independent BCPR (OR=0.84, 95% CI: 0.62-1.14, I2= 88.6%).

Conclusion This study found that DACPR resulted in significantly higher rates of BCPR as compared withindependentBCPRin OHCAs.Considering that DACPR also resulted in greater survival rate compared withno BCPR,DACPR should be a standard protocol for EMS systems worldwide.

Yu WANG, Yu WANG (Hefei,China, CHINA), Hong ZHANG
14:20 - 14:30 #18119 - OP047 Degeneration of Shockable Rhythm According to the No-flow Time for Out-of-Hospital Cardiac Arrest Patients.
OP047 Degeneration of Shockable Rhythm According to the No-flow Time for Out-of-Hospital Cardiac Arrest Patients.

Background

Patients for whom the out-of-hospital cardiac arrest (OHCA) is not witnessed are generally not considered eligible for extracorporeal resuscitation (E-CPR) because the duration before the initiation of their resuscitation (no-flow) is uncertain. It has previously been proposed that an initial shockable rhythm (SR) strongly suggested a short period of no-flow. The objective of this study was to describe the association between the duration between the initiation of the prehospital resuscitation and the presence of a SR for patients suffering from an OHCA.

Methods

The present cohort study used a registry of adult OHCA between 2010 and 2015 in Montreal, Canada. Adult patients suffering from a non-traumatic OHCA for whom the OHCA was witnessed, who did not have by-stander cardiopulmonary resuscitation were included. Patients who had a paramedic-witnessed OHCA were also included as a control group (no-flow time = 0 minutes). Patients who experienced a return of spontaneous circulation (ROSC) before the paramedics’ arrival or for whom the initial rhythm was not known were excluded. The evolution of the proportion of SR was initially described and a multivariable logistic regression controlling for pertinent demographic and clinical variables (e.g. age, gender, time of the day).

Results

A total of 1751 patients (male = 67%, mean age = 69 years [standard deviation = 16]) were included in the main analysis, of whom 603 (34%) had an initial shockable rhythm. A total of 663 other patients had their OHCA witnessed by paramedics. A shorter no-flow duration was associated with the presence of an initial SR (adjusted odds ratio = 0.97 [95% confidence interval = 0.94-0.99], p=0.016). However, this relation was not linear and the proportion of SR does not seem to lower until 15 minutes of no-flow duration (0 min = 35%, 1-5 min = 37%, 5-10 min = 35%, 10-15 min = 34%, more than 15 min = 16%).

Conclusion

Although the proportion of patients with a SR decreases as the no-flow duration increase, this relationship does not appear to be linear. The main decline in the proportion of patients with SR seems to occur after the fifteenth minute of no-flow time.

Dr Alexis COURNOYER (Montréal, CANADA), Sylvie COSSETTE, Raoul DAOUST, Judy MORRIS, Jean-Marc CHAUNY, Brian POTTER, Luc DE MONTIGNY, Dave ROSS, Luc LONDEI-LEDUC, Yoan LAMARCHE, Jean PAQUET, Martin MARQUIS, Éric NOTEBAERT, Francis BERNARD, Martin ALBERT, Éric PIETTE, Yiorgos Alexandros CAVAYAS, André DENAULT
14:30 - 14:40 #18370 - OP048 Urban-Rural gap in Effectiveness of Dispatcher-Assisted Cardiopulmonary Resuscitation.
OP048 Urban-Rural gap in Effectiveness of Dispatcher-Assisted Cardiopulmonary Resuscitation.

Background:

  Out-of-hospital cardiac arrest (OHCA) is the leading cause of death worldwide. Dispatcher-assisted cardiopulmonary resuscitation (DACPR) is an effective intervention to promote early bystander CPR and improve survival outcome in patients with OHCA. The different effectiveness of implementing DACPR in urban and rural areas has not been explored.

Methods:

  This is a prospective observational study. It was carried out in Taichung County, which is consisted with urban, suburban and rural areas. In 2018, Taichung had more than 2.8 million residents and more than 2500 patients with OHCA. We have been promoting DACPR since 2015. All dispatchers have received at least 8-hour training on providing DACPR instructions. After two years of running-in, DACPR was implemented steadily in Taichung.

  All OHCA cases occurred in Taichung County from July 1, 2017 to November 30, 2018 were included in the study. Those appeared apparent death, refused hospital referral, aged younger than 20 years and those who with cardiac arrest consecutive to trauma were excluded. Those who lacked audio file records were also excluded. Prehospital data were collected according to the Utstein-style template. The primary outcome of this study was to determine the urban-rural gap in the proportion of bystander performed CPR after dispatchers identified cardiac arrest status. Patient’s outcome, such as return of spontaneous circulation (ROSC) before hospital arrival, 2-hour survival rate, and neurological outcomes were also recorded.

 

Results

  A total of 2716 patients were enrolled in this study after excluded those who met the aforementioned exclusion criteria. Patients with OHCA in the rural areas were older than urban areas (71.0±16.4 in urban areas, 69.68±15.8 in suburban areas, and 73.03±14.9 in rural areas respectively, p = 0.006). When compared with urban areas, emergency medical services response time was increased in rural areas. There was no difference in gender, types of location where cardiac arrest occurred, witness of arrests and initial shockable arrests.

  There was no difference in the recognition of cardiac arrest between urban and rural areas. However, after the dispatchers identified cardiac arrests, the proportion of bystanders who performed CPR in urban areas is higher than in rural areas (75.87% in urban areas, 73.46% in suburban areas and 67.73% in rural areas). The urban area has a relatively higher chance to achieve ROSC, and has a relatively higher proportion patients survived with favorable neurological function, but those had not reached statistical significance.

 

Conclusion

The study found that in the same dispatch center, bystanders in urban areas had a higher rate of acceptance and perform of cardiopulmonary resuscitation. Although no statistically significance, it was found that patients with OHCA in urban areas had a better prognosis. In the future, public health and public education are need to make people more likely to perform cardiopulmonary resuscitation and achieve more bystander cardiopulmonary resuscitation.

Hong-Mo SHIH, Shao-Hua YU (Taichung, TAIWAN)
14:40 - 14:50 #18530 - OP049 Thrombolysis during resuscitation for out-of-hospital cardiac arrest caused by pulmonary embolism increases 30-day survival: findings from the French National Cardiac Arrest Registry.
OP049 Thrombolysis during resuscitation for out-of-hospital cardiac arrest caused by pulmonary embolism increases 30-day survival: findings from the French National Cardiac Arrest Registry.

Background: Pulmonary embolism (PE) represents 2% to 13% of all causes of out-of-hospital cardiac arrest (OHCA) and is associated with extremely unfavorable prognosis. In PE-related OHCA, inconsistent data showed that thrombolysis during cardiopulmonary resuscitation (CPR) may favor survival.

Methods: It was a retrospective, observational, multicenter study from the French National OHCA. All adult OHCA, managed by a mobile intensive care unit, and with a diagnosis of pulmonary embolism confirmed on hospital admission were included. PE was diagnosed on hospital admission by computed tomography pulmonary angiography (CTPA) (definite PE) or echocardiogram (probable PE). We excluded all other causes of OHCA and patients who had ROSC prior to mobile intensive care unit management. Patients were classified in two groups: those who received thrombolytic therapy during cardiopulmonary resuscitation and those who did not. The primary end point was day-30 survival in a weighted population. In order to obtain unbiased estimations of the average treatment effects, we used inverse probability of treatment weighting (IPTW). This method was performed in two steps: first, an estimation of the propensity score of treatment (thrombolysis during cardiopulmonary resuscitation) with a logistic model, and then an estimation of the effect of treatment on 30-day survival, weighted on the propensity score. The present study was approved by the French Advisory Committee on Information Processing in Health Research (CCTIRS) and the French National Data Protection Commission. It was approved as a medical assessment registry without requirement for patient consent.

Results: From July 2011 to March 2018, of the 14,253 patients admitted to the hospitals, 328 had a final diagnosis of PE and 246 were included in the analysis. In the group that received thrombolysis during resuscitation (n=58), 14 received alteplase (24%), 43 tenecteplase (74%) and 1 streptokinase (2%). Thirty-day survival was higher in the thrombolysis group than in the control group (16% vs 6%, P=0.005; adjusted log-rank test) but the good neurological outcome was no significantly different (10% vs 5%; adjusted relative risk = 1.97 CI95[0.70–5.56]). Median duration of stay in the intensive care unit (ICU) was 1 (0-5) day in the thrombolysis group and 1 (0-3) day in the control group (P=0.23). Mortality on day 0 (i.e., day of the OHCA) was 34% in the thrombolysis group and 37% in the control group (P = 0.76). Among all survivors at day 30, the median time until ICU discharge was 10 (4-21) days. Subjects in the thrombolysis group would not die of hemorrhage any more than those in the control group (6% vs 5%; P = 0.73). On the other hand, irreversible coma appeared slightly less frequent as a cause of death in the thrombolysis group (2% vs 11%; P = 0.05).

Conclusions: In OHCA patients with confirmed PE and admitted with recuperation of spontaneous circulation in the hospital, there was significantly higher 30-day survival in those who received thrombolysis during CPR compared with patients who did not receive thrombolysis. Randomized controlled trials are needed to define the role of thrombolysis in the management of suspected PE-related OHCA.

François JAVAUDIN (Nantes), Jean-Baptiste LASCARROU, Quentin LE BASTARD, Quentin BOURRY, Hugo DE CARVALHO, Philippe LE CONTE, Joséphine ESCUTNAIRE, Hervé HUBERT, Emmanuel MONTASSIER, Brice LECLERE
14:50 - 15:00 #18988 - OP050 Effect of the floor level on a neurologically favorable discharge after cardiac arrest according to the event location.
OP050 Effect of the floor level on a neurologically favorable discharge after cardiac arrest according to the event location.

Background:

Increases in the population concentrations in urban areas have led to increases in the numbers of people who live in high-rise buildings. Several studies reported the negative outcomes of patients who experience OHCA in high-rise buildings. Despite the above findings, we assumed that an increased vertical distance would always lead to a delayed EMS response time, as high-rise buildings tend to be densely populated and located in traffic center. This study aimed to compare the emergency medical service (EMS) response times and probability of a neurologically favorable discharge among patients who suffered an out-of-hospital cardiac arrest (OHCA) while on a high or low floor at home or in a public place.

Methods:

This retrospective analysis was based on Smart Advanced Life Support registry data from January 2016 to December 2017. Patients older than 18 years who suffered an OHCA due to medical causes were included in this study. Patients who were not resuscitated because of obvious signs of death, a refusal of CPR, do-not-resuscitation (DNR) state, or medically directed cessation of CPR; whose CA was witnessed by 911-initiated first responders; or who had incomplete data were excluded. A high floor was defined as the ≥3rd floor above ground. We compared the probability of a neurologically favorable discharge according to the floor level and location (home vs. public place) of the OHCA event. Additionally, we calculated the call-to-scene and call-to-patient times after OHCA for patients classified into the high and low (<3rd) floor groups according to the CA event location.

Results:

Of the 6,335 included OHCA cases, 4,154 (65.6%) events occurred in homes. Rapid call-to-scene times for high floor events were reported in both homes and public places. A longer call-to-patient time was observed for home events. Among OHCA events that occurred on high floors, the likelihood of a neurologically favorable discharge was significantly lower if the event occurred in a public place (adjusted odds ratio [aOR]=0.58) but higher if the event occurred at home (aOR=1.49).

Discussion & Conclusions:

Both the EMS response times to OHCA events in high-rise buildings and the probability of a neurologically favorable discharge differed between homes and public places. The results suggest that the prognosis of an OHCA patient is more likely to be affected by the building structure and use rather than the floor height.

Choung Ah LEE (Hwaseong, KOREA), Han Joo CHOI, Hyung Jun MOON, Won Jung JEONG, Gi Woon KIM
15:00 - 15:10 #19052 - OP051 Implementation of Dispatcher-assisted CPR was associated not only with better survival rates but also with increased number of cardiac arrest patients found by EMS with ventricular fibrillation.
OP051 Implementation of Dispatcher-assisted CPR was associated not only with better survival rates but also with increased number of cardiac arrest patients found by EMS with ventricular fibrillation.

Background

Many studies confirmed that dispatcher-assisted CPR (D-CPR) could improve survival from out-of-hospital cardiac arrest (OHCA) by significant improvement of bystander-CPR (B-CPR) rates. The aim of this study was to confirm relation between D-CPR implementation, incidence of cardiac arrest patients found by EMS with ventricular fibrillation (VF OHCA) and survival from VF OHCA from long-term (15 years) perspective.

Method

This is a retrospective analysis of Prague Utstein-style OHCA registry from the beginning of D-CPR implementation (2003) until the end of 2018. Survival from cardiac arrest was defined as survival with cerebral performance category 1 or 2 during 30 days follow-up after OHCA.

Results

During first ten years of D-CPR implementation, B-CPR rates increased from 13,6%  to 81,0% (p<0,0001) and then remained more or less stable for following 6 years. This process was in strong correlation with VF OHCA incidence (Pearson R score = 0,684; P-Value = 0,003) as well as with VF OHCA survival rate (Pearson R score = 0,782; P-value = 0,00011). 

Conclusion

VF OHCA incidence as well as VF OHCA survival rates were in a strong correlation with D-CPR implementation as measured by B-CPR ratios. This supports the hypothesis that D-CPR increases survival from OHCA not only by improving survival rates, but also by keeping more patients with ventricular fibrillation running until EMS arrival.

Ondrej FRANEK (PRAHA, CZECH REPUBLIC), Jaroslav PEKARA
15:10 - 15:20 #19153 - OP052 Comparison between emergency physicians’ decision to hospitalize or discharge home and clinical risk categories of the MEESSI scale among patients with acute heart failure.
OP052 Comparison between emergency physicians’ decision to hospitalize or discharge home and clinical risk categories of the MEESSI scale among patients with acute heart failure.

Objective: The MEESSI is a validated clinical decision tool that characterizes risk of mortality in emergency department (ED) acute heart failure (AHF) patients. The objective of this study was to compare the distribution of risk categories between hospitalized and discharged ED patients with AHF.

Methods: We included consecutive AHF patients from 34 Spanish EDs. Patients were retrospectively classified according to MEESSI risk categories. We calculated the odds of hospitalization (vs. direct discharge from the ED) across MEESSI risk categories. Next we assessed the following 30-day post-discharge outcomes: ED revisit, hospitalization, death, and their combination. We used Cox hazards models to determine the adjusted association between ED disposition decision and the outcomes among patients who were stratified into low and increased risk categories.

Results: We included 7,930 patients [age=80.5 (SD=10.1) years; women=54.7%; hospitalized=75.3%]. Compared to low-risk MEESSI patients, OR for hospitalization of patients in intermediate, high and very-high risk categories were 1.83 (1.64-2.05), 3.05 (2.48-3.76) and 3.98 (3.13-5.05), respectively. However, almost half (47.6%) of all discharged patients were categorized as increased risk by MEESSI, and 19.0% of all the increased risk patients were discharged from the ED. Among the low-risk MEESSI patients, the 30-day post-discharge mortality did not differ by ED disposition (HR for discharged patients respect to hospitalized 0.65, 0.70-1.11), nor did it differ in the increased risk group (0.88, CI 0.63-1.23). The low risk MEESSI patients had higher risks of 30-day ED revisit and hospitalization (1.86, 1.57-2.20; and 1.92, 1.54-2.40; respectively) as did the increased risk group (1.62, 1.39-1.89; and 1.40, 1.16-1.68), with similar results for the combined endpoint[MO(1] .

Conclusions: The disposition decisions made in current clinical practice for ED AHF patients calibrate with MEESSI risk categories, but nearly half of the patients currently discharged from the ED fall into increased risk MEESSI categories.

Acknowledge of funding: This study was partially supported by grants from the Instituto de Salud Carlos III supported with funds from the Spanish Ministry of Health and FEDER (PI15/01019, PI15/00773, PI18/00393, PI18/00456) and Fundació La Marató de TV3 (2015/2510).

Oscar MIRO (Barcelone, SPAIN), Víctor GIL, Pablo HERRERO-PUENTE, Jacob JAVIER, Pere LLORENS, F. Javier MARTÍN-SÁNCHEZ, Xavier ROSSELLÓ
15:20 - 15:30 #19168 - OP053 Evolution of bystander intention to perform cardiopulmonary resuscitation after training : an online survey.
OP053 Evolution of bystander intention to perform cardiopulmonary resuscitation after training : an online survey.

Background:

Early cardiopulmonary resuscitation (CPR) dramatically increases the chances of neurologically intact survival after cardiac arrest. CPR is however initiated by bystanders in less than half of all out-of-hospital cardiac arrests. The probability of starting CPR depends on the intention to perform resuscitation, which can be divided into three components: attitude, perceived norms, and self-efficacy. The aim of our study was to evaluate how these components change according to the time elapsed since the last CPR training.

Method:

After consultation of our local ethics committee, a web-based survey was created. Intention to perform CPR was assessed by 17 questions based on a 4-point Likert scale.

A link to the survey was sent via e-mail by a Red Cross National Society affiliated CPR training centre based in Geneva, Switzerland, to all previous participants for whom an electronic address was available. No personal data other than that required for the demographic analysis was ever recorded or asked for.

After connection to the web site, a consent form and confidentiality statement were immediately displayed.

Surveys were excluded if they were completed by healthcare professionals, healthcare students, or if the last CPR training took place more than five years prior to our study.

Data was stored in an encrypted MySQL database, extracted to a comma-separated value file, and analysed using Stata 15. Participants were sorted in two groups according to their last CPR training (< 1 year and ≥ 1 year). Fisher’s exact test or chi-square test were used according to normality and sample size. A p value < 0.05 was considered significant.

Results:

3360 e-mails were sent at the end of January 2019. 162 surveys were included in our analysis (59 were excluded according to our criteria). There was no significant difference in demographics between the two groups.

Attitude: 5 out of 6 elements did not differ significantly. The ≥ 1 year group was more worried about the risk of contracting a transmissible illness in (p=0.010).

Perceived norms: 5 out of 6 elements did not differ significantly. Participants in the ≥ 1 year group were more prone to the risk of diffusion of responsibility (p=0.011).

Self-efficacy: 2 out of 5 elements did not differ significantly.  Participants in the ≥ 1 year group felt less confident about their ability to recognize a cardiac arrest (p < 0.001) and to perform CPR (p=0.029). They also felt they wouldn’t be helpful if they had to deal with a cardiac arrest (p=0.004).

Conclusion:

After CPR training, elements related to all three components determining the intention to perform CPR decreased significantly over time. This might prevent some bystanders from providing early CPR, and further research should therefore focus on means to prevent, avoid, or compensate this decrease, far beyond technical considerations.

Django ROSA (Geneva, SWITZERLAND), Mélanie SUPPAN, Robert LARRIBAU, Marc NIQUILLE, François SARASIN, Simon REGARD, Laurent SUPPAN
15:30 - 15:40 #19329 - OP054 Peer teaching model for basic life support in high school student.
OP054 Peer teaching model for basic life support in high school student.

Objective: It has been shown that initiation of early cardiopulmonary resuscitation (CPR) decreases morbidity and mortality of out-of-hospital cardiac arrest patients.Despite this information, the rate of early CPR application is low in most countries. Basic life support (BLS) training for the public is important to increase the rate of CPR application in out-of-hospital cardiac arrests. In this study we aimed to test the effectiveness of peer education method on the learning and application of BLS in high school students.

Method: The study was conducted in high school and grade one students were included in the study. Students are divided in two groups (Group A and Group B). Pre-test and post-test tests were applied before and after training to measure the awareness and knowledge of all students.At the beginning of the study pediatric emergency and pediatric intensive care physicians trained eight students in group A.  These eight students were given BLS instructor training.   Afterwards these students trained eight students in group B with same method and those eight students in group B became instructor.  Instructor students from both groups trained their friends in their own group.A medical doctor supervised every training session. Training session was not intervened unless there is wrong information transfer or unanswered question by instructor student.

Results:153 students were included in the study. 5 students were excluded from the study because they did not participate in the tests. There were 76 students in group A and 72 students in group B.There was a statistically significant improvement in 8 questions from 13 questions in the pre- and post-training knowledge tests (p <0.05). Students were able to give true answers regarding environmental safety, consciousness assessment, control of the airway and respiration, 30: 2 chest compression, 100 times chest compression, the hands placed in the middle of the chest. This situation was similar in two groups and there was no difference between two groups in terms of improvement in post-test performance.Students were evaluated in terms of BLS application competence. In the 16-step evaluation, the students in group A applied BLS with a success rate of 90.2% and B group with a success rate of 93.4%. In group A, it was found that the most successful steps were respiration control and performing 30: 2 chest compressions.Calling emergency call center step was the most forgotten step in group A.In Group B, most successful step was to provide environmental safety, the most forgotten step was to call emergency call center.In post-training awareness questionnaire, significant improvement was determined in terms of basic life support (BLS) hearing, understanding of BLS need, feeling sufficient to apply BLS, giving BLS training in schools and watching videos about BLS.

Conclusion:This is the first study testing the effectiveness of peer education method in BLS training of high school students. It was shown that with peer education model students could train other students as basic life support instructors. With the implementation and dissemination of this training model, BLS training can be given to the public much faster.

Ahmet Ziya BIRBILEN (Ankara, TURKEY), Selman KESICI, Damla HANALIOGLU, Zeynel OZTURK, Ozlem TEKSAM, Benan BAYRAKCI, Zeynep BAYRAKCI
TERRACE 2B
15:40 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
16:10

Monday 14 October

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A24
16:10 - 17:40

Major trauma
Changing the alphabet of trauma care
Trauma

Moderators: James CONNOLLY (Consultant) (Newcastle-Upon-Tyne, UK), Gareth ROBERTS (Doctor) (Manchester, UK)
16:10 - 17:40 A Primary Survey fit for the 21st Century. James CONNOLLY (Consultant) (Newcastle-Upon-Tyne, UK)
16:10 - 17:40 A is for archaic? Did the ATLS 10 go far enough? Dr Zaffer QASIM (Speaker) (Philadelphia, USA)
16:10 - 17:40 The one before A-Managing catastrophic hemmorrhage. Dr Clare BOSANKO (EM/PHEM) (Plymouth, UK, UK)
CONGRESS HALL

Monday 14 October

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B24
16:10 - 17:40

What characteristics does a good emergency physician have?
What does it take to be excellent in Emergency Medicine? Tips from the experts
General EM, Human factors, Soft skills

Moderators: Christian HOHENSTEIN (PHYSICIAN) (Madgeburg, GERMANY), Senad TABAKOVIC (Zürich, SWITZERLAND)
16:10 - 16:20 The 7 habits of a highly effective emergency physician (15 minute introduction talk). Dr Thomas FLEISCHMANN M.D. (Medical Director) (Rendsburg, GERMANY)
16:20 - 16:40 Panel Discussion 1. Greg HENRY (USA), Dr Thomas FLEISCHMANN M.D. (Medical Director) (Rendsburg, GERMANY)
16:40 - 16:50 Carry on erring: Would routinely cross-checking cases improve safety? Pr Yonathan FREUND (Emergency Physician) (Paris, FRANCE)
16:50 - 17:10 Panel Discussion 2. Greg HENRY (USA), Pr Yonathan FREUND (Emergency Physician) (Paris, FRANCE), Dr Thomas FLEISCHMANN M.D. (Medical Director) (Rendsburg, GERMANY)
17:10 - 17:20 Lecture 3. Greg HENRY (USA)
17:20 - 17:40 Panel Discussion 3. Greg HENRY (USA), Judith TINTINALLI (Professor) (Chapel Hill NC, USA), Dr Thomas FLEISCHMANN M.D. (Medical Director) (Rendsburg, GERMANY), Pr Yonathan FREUND (Emergency Physician) (Paris, FRANCE)
FORUM HALL

Monday 14 October

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C24
16:10 - 17:40

Resuscitation in different colors
Soft skills and philosophy of resuscitation
ARRHYTHMIAS, Stroke, Human factors, Wellbeing

Moderators: Wilhelm BEHRINGER (Director) (Jena, GERMANY), Marie-Laure BOUCHY JACOBSSON (Consultant) (Hellerup, DENMARK)
16:10 - 17:40 What is a good resuscitation? Maaret CASTREN (Professor) (HELSINKI, FINLAND)
16:10 - 17:40 Debriefing after a disaster in the resus room. Simon CARLEY (Consultant in Emergency Medicine) (Manchester, UK)
16:10 - 17:40 Are we still performing inappropriate CPR attempts at the end of life? Pr Suzanne MASON (Professor of Emergency Medicine) (Sheffield, UK)
SOUTH HALL 3AB

Monday 14 October

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D24
16:10 - 17:40

YEMD - Newest kids on the block
Prepared fresh just for you!
Communication, Fringe, Young Emergency Medecine

Moderators: Tom ROBERTS (Doctor) (Bristol, UK), Patricia VAN DEN BERG (Academic Clinical Fellow Emergency Medicine) (Manchester, UK)
16:10 - 17:40 Headache - cool new ideas for treatment. Dr Andrea DUCA (Emergency physician) (Bergamo, ITALY)
16:10 - 17:40 Cell salvage on the street? Dr Ross EVANS (Junior doctor) (Wolverhampton, UK)
16:10 - 17:40 The best of the best (yemd) abstracts. Youri YORDANOV (Médecin) (Paris, FRANCE)
17:10 - 17:20 #18213 - OP060 Bedside ultrasound in acute patients with suspected kidney involvement - a prospective observational study.
OP060 Bedside ultrasound in acute patients with suspected kidney involvement - a prospective observational study.

Background
Complicated urinary tract infections leading to treatment failure and readmissions is a common challenge in the emergency department (ED). An identified risk factor is obstructive uropathy. The diagnosis of hydronephrosis based on the initial clinical assessment and blood test in the emergency department is challenging.
Point-of-care ultrasound (POCUS) has the advantage of being non-radiating, rapid to apply and with increasing accessibility. POCUS has shown to be valuable when assessing the abdomen of trauma patients.
The aim of this study is to investigate incidence of hydronephrosis in patients presenting with symptoms of urinary tract infection or dehydration using POCUS in the ED and evaluate its clinical relevance and accuracy.

Methods
In this observational, prospective semi-blinded single-center study, patients were included based on preliminary diagnosis reported from general practitioner or from triage in the ED. Inclusion criteria were dehydration defined by laboratory values or urinary tract infections. In addition, patients had to present at least one of the following symptoms: Dysuria, flank pain, elevated creatinine or renal colic. Patients were collected as a convenience sample Patients were included if aged above 18 and able to perform written consent.
POCUS of the bladder and kidneys was performed within 4 hours after admission. Results from the POCUS was blinded to the treating physician (TP) until the first questionnaire concerning radiological prescriptions was completed. After revealing the POCUS results the TP evaluated the primary assessment through a second questionnaire.
Primary outcome was hydronephrosis and urinary retention. Secondary outcome was an evaluation of applicability. Relevance and applicability were answered by analysis of questionnaires and patient laboratory values using sensitivity and specificity, chi2-test and logistic regression. 

Results
153 patients were included during day and evening shift in the period November 4th 2018 to April 5th 2019. Hydronephrosis was found in at least one side in 10.5% (95% CI [0.98;0.22]) and urinary retention in 15.0% (95% CI [0.10;0.22]). 22.9% (95% CI [0.16;0.30]) presenting with either hydronephrosis or urinary retention. Hydronephrosis was not related to urinary retention in the study population (p=0.2384). 63 out of 150 TPs report by questionnaire POCUS to influence the clinical decision. TP prescribed further radiological examination in 9 of the 16 cases POCUS identified as having hydronephrosis (p=0.4340).

Discussion
Among limitations to this study is the single-center design and only two POCUS operators. Due to the sample size, correlations to predict subpopulations at risk for hydronephrosis remains weak. The non-coherence to urinary retention and TP assessment indicates the need for screening tools.
The use of questionnaires as measure of clinical consequence, lack specific values and actions, making it hard to analyze in terms of patient care and treatment.

Conclusion
This study found hydronephrosis in 1 in 10 included patients. Hydronephrosis based on clinical findings alone was rarely predicted, which supports POCUS as a valuable screening tool.

Pernilla G. BORGGAARD (Odense, DENMARK), Ole GRAUMANN, Christian LAURSEN B., Annmarie Touborg LASSEN, Stefan POSTH
17:20 - 17:30 #18301 - OP005 Implementation of ketamine-propofol (“ketofol”) in a 1 on 4 ratio for adult procedural sedation at a university hospital emergency department – case series report on safety and effectivity.
Implementation of ketamine-propofol (“ketofol”) in a 1 on 4 ratio for adult procedural sedation at a university hospital emergency department – case series report on safety and effectivity.

Background:

Procedural sedation is a frequently performed procedure at the emergency ward and emergency physicians should be capable of performing this safely, effectively and independently. For clinical guidance we composed an easy and unambiguous protocol for procedural sedation applicable for nearly all patients and procedures. Our sedative of choice is a mixture of ketamine and propofol (“ketofol”) in a 1 on 4 ratio. Both ketamine and propofol are known to neutralise each other’s undesirable effects and ketamine adds an analgesic quality. Ketofol has proven effective and safe in studies and is non-inferior to propofol. Though it is most often used in a 1 on 1 ratio, both pharmacological and clinical studies favour a 1 on 4 ratio. We hypothesize our protocol with ketofol 1 on 4 is safe and effective and will serve to facilitate procedural sedation by emergency physicians.

Methods:

All adults presenting at the emergency ward of the University Hospital of Ghent between February 2018 and April 2019 and in need of procedural sedation would be included in a prospective case series study. Informed consent was obtained for both the sedation and the study. Patients with an American Society of Anesthesiologist physical status classification system score (ASA-score) of III or more, with an anticipated difficult airway or intoxicated patients were discussed with the anaesthesiology department to decide the feasibility of sedation in the emergency ward setting. Pregnant patients were excluded. Ketofol 1 on 4 was prepared by mixing 1ml of ketamine (50mg) and 20ml of propofol (200mg) in a single syringe and administrated as a loading dose of 1ml/10kg, followed by a stepwise titration in aliquots of 0,5ml/10kg. Above 65 years the loading dose was halved. Registered patient outcomes were respiratory and hemodynamic events, vomiting, agitation or hallucinations, and amnesia. In addition we measured satisfaction of the physician with the performed sedation.

Results:

Sixty-one patients, between 18 and 89 years old, with an ASA-score ranging from I to III were included. Six respiratory events were registered in as many patients (9,8 %), none of them serious. All involved airway obstruction, alleviated by head tilt and chin lift and with no repercussion on vital signs save one brief episode of desaturation. There were no hemodynamic events. No vomiting was reported. Five patients (8,2%) experienced pleasant hallucinations or dreams and one patient (1,6%) was agitated upon awakening but calmed rapidly without additional medication. Amnesia was present in 58 patients (95,1%). Physician satisfaction rate was 93,4%.

Discussion & conclusions:

Implementation of our protocol ensured amnesia in majority of patients, with a low frequency of complications. Only minor respiratory events and agitation or hallucinations were observed. Respiratory events were reported slightly less than in studies using propofol or ketofol in different proportions. The rate of agitation or hallucinations is similar to that of propofol monotherapy, but lower than studies using ketofol 1 on 1. Our protocol, using ketofol in a 1 on 4 ratio, appears safe and effective and resulted in a high physician satisfaction rate.

Stig WALRAVENS (Ghent, BELGIUM), Evi STEEN , Walter BUYLAERT, Peter DE PAEPE
17:30 - 17:40 #19098 - OP114 Trends and Characteristics of Buprenorphine Sublingual Tablet Toxicities.
OP114 Trends and Characteristics of Buprenorphine Sublingual Tablet Toxicities.

Background: The number of patients with an opioid use disorder in the U.S. was estimated to be 2.6 million in 2015. Buprenorphine can be easily dispensed through office-based prescribers and community pharmacies, with 58% opioid treatment programs now offering buprenorphine. Buprenorphine sublingual tablets were discontinued in 2012 due to concerns about the misuse, abuse, and diversion. They were replaced with single dose sublingual films that are considered child-resistant and abuse deterrent. The objective of this study is to evaluate the trends, and characteristics of exposures to buprenorphine tablet formulations.

Methods: We retrospectively queried the National Poison Data System (NPDS) for all confirmed exposures to buprenorphine tablets from 1/1/2011 to 12/31/2016 as specified by the American Association of Poison Control Center Code (AAPCC) generic code and product name. We assessed the relevant characteristics of exposures descriptively. Frequencies and rates of buprenorphine tablet exposures (per 100,000 human exposures) were evaluated using Poisson regression methods, with the percent changes and corresponding 95% Confidence Intervals (95% CI) reported. Predictors of severe outcomes (major effects and death) to tablet exposures were also assessed with adjusted odds ratios (AOR) presented.

Results: Overall, there were 7,406 reports of exposures to buprenorphine sublingual tablets to the PCs during the study period. The reports of buprenorphine tablet exposures decreased from 1,780 to 468 during the study period, a decrease of 73.7% (95% CI: 64.1%, 78.7%; p<0.001), with exposures resulting in severe clinical outcomes decreasing from 49 in 2011 to 27 in 2016. The rate of exposures decreased by 71.3% during the study period. Children under 6 years of age represented 32.1% of the sample, while adults between 20 and 29 years of age accounted for 23.8% of the cases. The most common reason for exposure was unintentional (34.6 %), with intentional abuse (20.3%) being common (15.1%). Single substance exposures accounted for 63.9% of the cases and ingestion was the most common route of exposure. The case fatality rate for such exposures was 0.2%, with 3.9% cases demonstrating major effects. The proportion of major effects was highest among suspected suicides (9.5%) and abuse (4.5%) in comparison to cases of other exposure reasons such as unintentional. The Midwest region (37.4%) demonstrated the highest proportion of buprenorphine tablet exposures. An additional opioid was reported for 11.1% cases and naloxone was a commonly reported therapy for cases. Significant predictors of severe buprenorphine film exposures included suspected suicides (Ref: Unintentional reasons) (AOR: 1.96, 95% CI: 1.34 – 2.86), 3 or more co-occurring substances (AOR: 4.14, 95% CI: 1.87 – 9.14), and non-oral routes of exposure (AOR: 2.16, 95% CI: 1.31 – 3.56).   

Conclusions: Analysis of national data from the NPDS exhibited a significantly decreasing trend in the exposures to buprenorphine tablet products, with such exposures being frequent among children under 5 years of age. Considering the discontinuation of the sublingual tablets, it is imperative to explore in greater detail, the reasons for the observed exposures. Possible reasons for these observed exposures might be the continued availability despite discontinuation or potential diversion of the product

Saumitra REGE (Charlottesville, VA, USA), Marissa KOPATIC, Dr Christopher HOLSTEGE
SOUTH HALL 3C

Monday 14 October

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E24
16:10 - 17:40

PAEDIATRICS
Paediatric emergencies. Take your decision
INTERACTIVE SESSION, Pediatric, Trauma, Ultrasound

Moderators: Niccolò PARRI (Attending Physician) (Florence, ITALY), Patrick VAN DE VOORDE (Prof) (Ghent, BELGIUM)

16:10 - 17:40 Total body CT scan in trauma patients: Yes or No. Silvia BRESSAN (Moderator) (Padova, ITALY), Pr Said HACHIMI IDRISSI (head clinic) (Ghent, BELGIUM)
16:10 - 17:40 Ultrasound is the best modality to diagnose limb fractures in children. Yes or No. Dr Tom BEATTIE (Senior lecturer) (Edinburgh, UK), Dr Damian ROLAND (Paediatric EM) (@damian_roland, UK)
16:10 - 17:40 Head CT scan in headache: Yes or No. Pr Luigi TITOMANLIO (Head of Department) (Paris, FRANCE)
CHAMBER HALL

Monday 14 October

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F24
16:10 - 17:40

ABSTRACTS SESSION

Moderators: Helen ASKITOPOULOU (Chair Ethics Committee) (Heraklion, GREECE), Bulut DEMIREL (Emergency Department Chief) (Ankara, TURKEY)
16:10 - 16:20 #18967 - OP055 “Mind your Head” – a quality improvement project assessing the advice given to patients following a head injury in a London Emergency Department.
OP055 “Mind your Head” – a quality improvement project assessing the advice given to patients following a head injury in a London Emergency Department.

Introduction 

Head injuries and concussion have been highlighted for years in the media due to athletes sustaining either fatal or life changing consequences. Therefore, managing patients with head injuries is an essential skill of all Emergency Physicians. An extensive literature analysis identified several areas for improvement, one of which was the head injury advice given to those who had sustained an injury needs to be consistent and adequate in its explanation for patients regarding further care. A quality improvement project was undertaken at a District General Hospital Emergency Department (ED) in London, to improve the safety and long-term care of patients who have sustained a head injury (HI), by ensuring they have up-to-date written advice regarding concussion and partaking in sports and exercise after their injury.  

Methods

There was concurrent analysis of the number of patients attending the ED with minor head injuries and review of the documentation by ED staff regarding the written HI and return to play (RTP) advice, over a six-month period. Three plan-do-study-act (PDSA) cycles were undertaken: doctors giving head injury and RTP advice, prompting patients to ask for advice and lastly empowering the triage nurses to give HI/RTP advice on first contact with the patient. The team analysed the numbers of documented written HI advice after each cycle and made modifications.

Results

National Institute for Health and Care Excellence (NICE) guidelines expect 100% of all patients to have written HI advice, therefore our aim was to have all patients given written HI advice, and 70% receiving RTP advice after an injury. Our results showed that with improving awareness, teaching and access to HI and RTP advice, the number of patients receiving written HI advice improved. Over 71% of patients received written head injury advice after the 2nd PDSA cycle, and our rate of written RTP increased to 13%, from a baseline of zero. The third cycle showed a decrease in patients receiving written HI (60%) and RTP (6%) advice.

Conclusions

The results demonstrate the positive outcome of regular teaching and awareness for staff as well as patients in a busy Emergency Department. Appropriately documented discharge advice to patients on head injuries, concussion and their day-to-day activities is good medical practice. Adequate explanation of concussive symptoms to patients with head injuries and advising them correctly about further exercise and activity is good medical practice, as well as documenting the advice given. Improving staff knowledge in early recognition and long-term management of head injuries increased staff confidence in supplying RTP/HI advice. Our next steps are to establish a head injury/concussion clinic within our ED, with due consideration of making an “App” designed for patient use during and after their attendance in the ED.

Dr Dominika GOROSZENIUK (London, UK), David SHACKLETON, Ashish JHALA, Patrick QUINN, Max FRIEDMAN
16:20 - 16:30 #18441 - OP056 Serum Cholesterol Level as Prognostic Factor in Post-cardiac Arrest Patients.
OP056 Serum Cholesterol Level as Prognostic Factor in Post-cardiac Arrest Patients.

Background: Low cholesterol level has been investigated as the risk factor of onset of sepsis and prognostic factor of mortality. Sepsis is complicated inflammatory process with ischemic-reperfusion injuries. Post-cardiac arrest syndrome also has global ischemic-reperfusion injury and considered as sepsis-like syndrome due to the severe inflammatory process. In previous study, oxidative stress was elevated and cholesterol levels were lower in post-cardiac arrest patients compared to normal patients. The aim of this study was to investigate whether initial serum cholesterol levels can predict the survival discharge and neurologic outcome in post-cardiac arrest patients.

Methods: This was a retrospective observational study performed in a tertiary care teaching hospital in South Korea from January 2012 to June 2018. Patients visiting emergency room (ER) with cardiac arrest or with recovery from cardiac arrest were screened. Patients followed by return of spontaneous circulation (ROSC) and admission for post cardiac arrest care were included. Patients who is younger than 18 years old and who did not take serum cholesterol level test were excluded. Patients were managed as Korean guideline of advanced cardiopulmonary life support (ACLS), 2015. After ROSC, all the patients were received post cardiac arrest care including targeted temperature management (TTM). Demographics, underlying disease, variables related to cardiac arrest, laboratory findings, radiologic data, received management, severity score as sequential organ failure assessment (SOFA) and variables related to outcome were collected. Cerebral performance category (CPC) was used as scoring system of neurological outcome. CPC 1 or 2 were defined as good neurological outcome and CPC 3 to 5 were defined as bad neurological outcome. The significance of intergroup differences was assessed by Fisher’s exact test or Mann-Whitney U test. Multiple logistical regression analysis was performed to identify the factors that could be considered independent factor for the prognosis. The performance to predict prognosis was checked using the area under the receiver operating characteristic curves (AUROC).

Results: 355 patients were enrolled. 192 patients (54.1%) were survived at discharge. 76 patients (21.4%) at discharge and 64 patients (18.0%) at 1 month after discharge had good CPC. Cholesterol levels at admission were significantly high in patients with survival (p=0.01), good CPC at discharge (p=0.00) and good CPC at 1 month after discharge (p=0.00). Multivariate logistic regression revealed that duration of CPR and cardiac cause, SOFA score were the predicting factor of survival (p=0.00). Predicting factors of good CPC at discharge were duration of CPR and cardiac cause, cholesterol level(p=0.000). Predicting factors of good CPC at 1 month after discharge were duration of CPR and cardiac cause, SOFA score, cholesterol level (p=0.000). AUROC of the cholesterol to predict survival, good CPC at discharge and 1 month after discharge were 0.603, 0.696 and 0.710, respectively.

Conclusions: Serum cholesterol level at admission was higher in survived patients and patients with good neurologic outcome. Duration of CPR, cause of arrest and SOFA score were predicting factor of survival and good neurological outcome. Serum cholesterol level at admission was one of the predicting factors for good neurological outcome in post cardiac-arrest patient.

Min Jung Kathy CHAE, Eun Jung PARK (Suwon, KOREA)
16:30 - 16:40 #18605 - OP057 The effects of thoracic cage dimension and chest subcutaneous adipose tissue on outcomes of adults with in-hospital cardiac arrest: A retrospective cohort study.
OP057 The effects of thoracic cage dimension and chest subcutaneous adipose tissue on outcomes of adults with in-hospital cardiac arrest: A retrospective cohort study.

Background: Increasing evidence has revealed that an adequate but uniform compression depth may not be suitable for all adults with various body sizes. The thoracic anteroposterior (AP) diameter is a commonly used parameter to reflect the thoracic cage dimension. Delivery of an adjustable compression depth based on thoracic AP diameter is recommended in pediatric resuscitation guidelines, but whether the thoracic cage dimension has impact on the prognosis for adult patients with cardiac arrest remains under debate. revealed the association between increasing SAT depth and compression inadequacy. But to date, whether the SAT-caused compression inadequacy leads to adverse outcomes of patients with cardiac arrest was unknown. This study aimed to investigate the associations between thoracic cage dimension, chest subcutaneous adipose tissue (SAT) depth and outcomes of adults with in-hospital cardiac arrest (IHCA).

Methods: We retrospectively evaluated patients with IHCA between January 2016 and October 2017. The thoracic cage transverse diameter, internal AP diameter, cross-sectional area, anterior and posterior SAT depths were measured in computed-tomography (CT) images using the three-dimensional visualization software (Mimics Interactive Medical Image Control System, Version 17.0, Materialize Company, Belgium). Using logistic regression models, we determined the adjusted associations between thoracic cage dimension, SAT depths and the prognosis for IHCA. The primary outcome was sustained return of spontaneous circulation (ROSC) and the secondary outcome was survival to hospital discharge.

Results: Among 423 IHCA patients, 258 patients achieved ROSC and 70 survived to discharge. Smaller cross-sectional area and posterior SAT depth were significantly related to ROSC. Smaller posterior SAT depth was associated with ROSC. After multivariate adjustment, the smaller cross-sectional area was independently associated with ROSC (Odds ratio [OR] 0.99, 95% confidence interval [95%CI] 0.99-1.00; p = 0.008) and survival to discharge (OR 0.99, 95%CI 0.98-1.00; p = 0.024), and the smaller posterior SAT depth was independently related to ROSC (OR 0.65, 95%CI 0.44-0.96; p = 0.030), whereas no relation to survival to discharge was found.

Conclusions: In adults with IHCA, the smaller thoracic cage dimension and posterior SAT depth are associated with better survival. An adjustable compression depth based on the thoracic cage dimension might be better than the “one-size-fits-all” compression depth for resuscitating CA patients. In addition, physicians should pay extra attention to compression efficacy when resuscitating obese patients.

Junzhao LIU (Chengdu, China, CHINA), Sheng YE, Yarong HE, Yu CAO
16:40 - 16:50 #18642 - OP058 Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: a retrospective multi-centre study.
OP058 Cut-off values of serum potassium and core temperature at hospital admission for extracorporeal rewarming of avalanche victims in cardiac arrest: a retrospective multi-centre study.

Aim: About 165 avalanche deaths are recorded per year in Europe and in North-America. Survival analyses suggest that most completely buried avalanche victims die by asphyxiation between 15 and 35 minutes after burial. Unlike asphyxia, hypothermia develops after long burial if the completely buried avalanche victim is able to breathe. These avalanche victims may recover without neurological sequelae. Recommendations for the pre-hospital triage of avalanche victims were based on expert consensus and case series with, admittedly, low levels of evidence and have not previously been validated using a large dataset. This study attempted to find reliable cut-off values for the identification of hypothermic avalanche victims with reversible out-of-hospital cardiac arrest (OHCA) at hospital admission. This may enable hospitals to allocate extracorporeal life support (ECLS) resources more appropriately while increasing the proportion of survivors among rewarmed victims.

Methods: This was a retrospective multi-centre study. Seven European hospitals that are capable of ECLS and have admitted avalanche victims with OHCA participated in the study: Bern (Switzerland), Grenoble (France), Innsbruck (Austria), Krakow (Poland), Tromsø (Norway), Lausanne and Sion (Switzerland). Approval by local institutional review boards was provided by the participating hospitals. All admitted avalanche victims with OHCA from 1995 to 2016 were included. To identify parameters that contribute independently to survival we performed a stepwise logistic regression on survival with respect to sex, age, duration of burial, core temperature, serum potassium and pH. Optimal cut-off values, for the parameters identified by logistic regression, were determined by means of bootstrapping and exact binomial distribution and served to calculate sensitivity, rate of overtriage, positive and negative predictive values, and receiver operating curve (ROC) analysis.

Results: In total, 103 avalanche victims with OHCA were included. Of the 103 patients 61 (58%) were rewarmed by ECLS. Six (10%) of the rewarmed patients survived whilst 55 (90%) died. The observed maximum value for core temperature in survivors was 27.8 °C. For serum potassium the observed maximum value in survivors was 4.8 mmol/L. In multivariate analysis logistic regression the parameters core temperature (p=0.02) and serum potassium (p=0.03) were statistically, significantly related to survival. Using cut-offs of 7 mmol/L and 30°C resulted in an overtriage rate of 47% (95% CI 35%-60%), negative predictive value of 100% (95% CI 92%-100%) and positive predictive value of 19% (95% CI 8%-35%). We obtained optimal cut-off values of 7 mmol/L for serum potassium and 30°C for core temperature.

Conclusion: For in-hospital triage of avalanche victims admitted with OHCA, serum potassium accurately predicts survival. The combination of the cut-offs 7 mmol/L for serum potassium and 30°C for core temperature achieved the lowest overtriage rate and the highest positive predictive value, with a sensitivity of 100% for survivors. The presence of vital signs at extrication is strongly associated with survival. For further optimisation of in-hospital triage, larger datasets are needed to include additional parameters.

Hermann BRUGGER, Pierre BOUZAT, Mathieu PASQUIER, Peter MAIR, Julia FIELER, Tomasz DAROCHA, Marc BLANCHER, Matthieu DE RIEDMATTEN, Markus FALK, Peter PAAL, Giacomo STRAPAZZON, Ken ZAFREN, Dr Monika BRODMANN MAEDER (Bern, SWITZERLAND)
16:50 - 17:00 #19331 - OP059 The development of a resuscitation record at an academic hospital: a survey and focus group of Code Blue team members.
OP059 The development of a resuscitation record at an academic hospital: a survey and focus group of Code Blue team members.

Background: A Code Blue is activated when a hospitalized patient suffers a cardiac arrest. Accurate documentation of the resuscitation effort is required in order to provide reliable data that will facilitate decision-making, code team debriefing, and inform quality improvement initiatives related to Code Blues. The documentation of Code Blues is not well defined by current guidelines and varies considerably between institutions. Using a survey and focus group, we aimed to improve our Code Blue documentation record in order to increase its completion rate and capture evidence-based quality metrics.

Methods: This study was reviewed and approved by the Queen’s University Health Sciences & Affiliated Teaching Hospitals Research Ethics Board and conducted from January to May, 2019. We distributed a 16-question survey containing a mixture of short answer, multiple choice, ranked, and narrative feedback questions to volunteer Code Blue personnel, including staff from nursing, respiratory therapy, anesthesiology, and emergency medicine. The survey aimed to assess their perceptions of the current resuscitation record by evaluating: 1) the individual priorities of members of the resuscitation team as they pertain to information recording; 2) features of the documentation that facilitate or hinder accurate information recording; and 3) types of information necessary for making treatment decisions and debriefing after the event. We then conducted a focus group with the Code Blue team to foster an interprofessional dialogue about the purpose of the resuscitation record and to create a framework that would guide the record’s redesign. With the aggregate feedback, we created three new resuscitation record templates that reflected the team’s content and formatting suggestions.

Results: The survey identified key information that the Code Blue team would need for decision-making and debriefing. In addition, several features of the current resuscitation record were minimally or improperly used and slowed recording of the event. These included outdated medication fields and terminology, formatting that limited complete information recording, and a lack of prompts for key information. The focus group re-iterated this feedback and proposed suggestions that were separated into content redesign, which reflects the completeness and relevance of recorded information, and formatting redesign, which reflects the ease and accuracy of recording information. The three new templates contained increasing degrees of content and formatting redesign compared to the original resuscitation record. Our next steps are to select one template through consensus that best closes the gaps in information recording identified by the Code Blue team.

Discussion & Conclusion: Accurate documentation during a Code Blue is critical in order to provide high-quality data that will drive the improvement of decision-making, debriefing, and ultimately patient outcomes. This study aimed to highlight shortcomings in the current documentation and strategies to improve the relevance and accuracy of information recorded during a resuscitation. We used a survey and focus group to perform a needs assessment of Code Blue team members and guide the redesign process in an evidence-based manner.

Danny JOMAA (Kingston, CANADA), Tim CHAPLIN
17:10 - 17:20 #18469 - OP061 Novel wearable cooling device for early initiation of targeted temperature management in the emergency department: a retrospective cohort study.
OP061 Novel wearable cooling device for early initiation of targeted temperature management in the emergency department: a retrospective cohort study.

Aim: Targeted temperature management (TTM) is an important component of post-cardiac arrest care. Although the optimum cooling method is not known, studies have suggested that prompt and quick cooling is associated with better outcomes. The aim of this study was to evaluate the cooling efficacy of a protocol including a novel cooling device in the Emergency Department (ED).

Methods: This was a single-center pre-post cohort study of post-cardiac arrest patients with return of spontaneous circulation (ROSC), for whom TTM was initiated at a tertiary hospital between April 2010 and December 2017. A surface cooling device (CarbonCool, Global Healthcare Pte Ltd), which uses a graphite cooling material in an insulating suit, was introduced in July 2015. Control patients enrolled before the intervention period received icepacks in the ED and cold saline. For both periods, the target temperature was 34.0oC, with TTM continued in the ICUs. The primary outcome was time from ROSC to target temperature (TT).

Results: Of 124 patients included, 40 were in the intervention period and 84 in the control period. Time from ROSC to TT was significantly lower in the intervention period at 119 (Interquartile range (IQR): 65-250) minutes versus 482 (IQR: 356-596) minutes (p<0.001). There was no statistical difference in survival to discharge (30.0% versus 32.1%, p=0.839) and Glasgow-Pittsburg Outcome scores (1 or 2 in 17.5% versus 21.4%, p=0.811). The intervention period also had a faster cooling rate (initiation of TTM to TT of 73 (IQR: 40-150) versus 142 (IQR: 75-262) minutes, p=0.014). There were no reported serious adverse events associated with the device.

Conclusion: Use of a novel cooling device in the ED resulted in a shorter time to target temperature. As it is reusable and does not require a power source, it has potential to be an affordable solution for pre-hospital and transport cooling. 

Leong Gen YAP, Nur SHAHIDAH (Singapore, SINGAPORE), Sohil POTHIAWALA, Kenneth B.k. TAN, Aaron S.l. WONG, Duu Wen SEWA, Eric T.s. LIM, Chee Tang CHIN, Marcus E.h. ONG
17:20 - 17:30 #18535 - OP062 Thirty-day mortality in atrial fibrillation patients with gastrointestinal bleeding in the emergency department: differences between direct oral anticoagulant and warfarin users.
OP062 Thirty-day mortality in atrial fibrillation patients with gastrointestinal bleeding in the emergency department: differences between direct oral anticoagulant and warfarin users.

Background:

The ageing of the population, the better knowledge of the cardio-embolic risk and the availability of new oral anticoagulant drugs that do not require continuous laboratory monitoring, have allowed an exponential spread of oral anticoagulant therapy. More clinical data are required on the safety of direct oral anticoagulants (DOACs). Although patients treated with warfarin and DOACs have a similar risk of bleeding, short-term mortality after a gastrointestinal bleeding (GIB) episode in DOAC-treated patients has not been clarified.

Objectives: To assess differences in 30-day mortality in patients treated with DOACs or warfarin admitted to the emergency department (ED) for GIB.

Methods: This was a multicentre retrospective study conducted over two years. The study included patients evaluated at three different EDs for GIB during oral anticoagulant therapy. The baseline characteristics were included. The two treatment groups (DOACs vs warfarin) were compared to evaluate any possible imbalance in the anamnestic or clinical characteristics. Here, the use of propensity score matching had to be considered to equilibrate the two groups and to obtain a homogeneous cohort of patients for prognostic evaluation. Comparison with the clinical and anamnestic variables was performed using the Mann–Whitney U test and with Fisher’s exact test, as appropriate. Cox regression, adjusted for all variables that were significant to the previous univariate analysis, was performed to verify differences in mortality between the two treatment groups. Finally, the Kaplan–Meier method was used to compare 30-day survival between DOAC and warfarin users. Results: Among the 284 patients presenting GIB enrolled in the study period, 39.4% (112/284) were treated with DOACs, and 60.6% (172/284) were treated with warfarin. Propensity score matching was not needed, as the two groups did not show significant differences in anamnestic or clinical characteristics except for the concomitant platelet therapy (11.6% vs 2.7%, p = 0.007). Overall, 8.1% (23/284) of patients died within 30 days. The factors associated with 30-day mortality risk were age, history of chronic renal disease, active cancer, HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly) value, and bleeding type (major GIB) and site (upper GIB). After the univariate analysis, neither of the two anticoagulant treatments resulted in higher 30-day mortality risk (warfarin 8.7% vs DOACs 7.1%, p = 0.824). Cox analysis adjusted for age, chronic renal disease, major GIB, upper GIB, and baseline HAS-BLED, showed no difference in mortality within 30 days of the GIB episode between the two groups (p=0.533). The Kaplan–Meier curves showed no difference in 30-day survival between the warfarin and DOAC users (p = 0.651).

Conclusions: Despite their rapid diffusion, the available evidence ON DOACs is lacking, and the GIB prognosis of anticoagulated patients remains unclear. The present study shows no differences between DOACs and warfarin in short-term mortality after GIB.

Gianni TURCATO, Dr Antonio BONORA (VERONA, ITALY), Elisabetta ZORZI, Arian ZABOLI, Alice DILDA, Massimo ZANNONI, Giorgio RICCI, Antonio MACCAGNANI, Norbert PFEIFER, Andrea TENCI
17:30 - 17:40 #18586 - OP063 Survey to detect unmet palliative care needs in the emergency department: First results of a questionnaire-based two-level screening process.
OP063 Survey to detect unmet palliative care needs in the emergency department: First results of a questionnaire-based two-level screening process.

Background and Objectives: The use of a screening tool to identify palliative care needs leads to a reduction of unwanted and highly invasive interventions in emergency patients with terminal illnesses.

Many of these patients enter clinical care through prehospital emergency medical services (EMS) and the emergency department (ED). Screening for palliative care needs at this interface can reduce loss of information and strengthen the patient’s autonomy in further clinical treatment.

 

Methods: We developed a two-level questionnaire summarizing existent criteria which indicate palliative care needs. Terminal illness and/or progressive malignant disease and a negative answer to the “Surprise-Question - Would you be surprised if the patient dies within the next 12 months due to their condition?” function as inclusion criteria to the screening process.  

Level 1 asks for the patient´s wishes, advanced directives, load of symptoms, psychosocial background and resources, as well as assignment from a nursing home. These questions are meant to be answered by the preclinical emergency medical team.

Level 2 is directed to the emergency physician at the ED. It is meant to confirm the surprise question and gives further detail about the terminal illness of the patient. Furthermore, it assesses if the patient has already been admitted to the hospital within the last 3 months.

As the investigation progresses, our defined goal is to determine the sensitivity and specificity, as well as the predictive values of our screening questionnaire. Therefore, we compare the assessment to a specialised palliative care physician´s consultation as gold-standard to evaluate palliative care needs. For the statistical analysis, we will use the binary logistic regression model.

 

Results: The eligibility criteria were met in 15 cases in which the availability of a palliative care consultation was given, too. 73% (11/15) of the patients who underwent the screening process were assigned through EMS, the remaining quarter was detected in the triage process at the ED.

Screening level 2 confirmed in 93.3% (14/15) the underlying terminal disease and in every case (15/15) a “No” to the “Surprise-Question”. 40% (6/15) of the trial participants passed away before the consult took place. Palliative care needs were confirmed in 8 out of 9 consultations (88.8%). 46.6% (7/15) of the study population died within the ED under palliative treatment, four further participants died during the hospital stay – overall 80%.

 

Discussion: We present data deriving from the first two months of experience after initiating the survey to show the feasibility of the two-level questionnaire concept.

The implemented screening process was suitable to adopt the strategy of care in the emergency department. In several cases palliative care and support of the patients and their families can be performed.

Ellen GOEBEL (Essen, GERMANY), Sven BUECHNER, Bernhard MALLMANN, MD, MBA, Ute VON FRANTZKI, Simone LAPORTE, MD, Randi MANEGOLD, MD, Carola HOLZNER, MD, Dirk PABST, MD, Clemens KILL, MD, Joachim RISSE, MD
TERRACE 2B
17:40

Monday 14 October

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B25
17:40 - 18:45

DIPLOMA & CERTIFICATE

17:40 - 18:45 Introduction. Luis GARCIA-CASTRILLO (ED director) (AARTSELAAR, BELGIUM), Pr Lisa KURLAND (speaker) (Örebro, SWEDEN)
17:40 - 18:45 EMERGE EBEEM announcement.
17:40 - 18:45 European Board Examination of Emergency Medicine diplomates ceremony. Ruth BROWN (Speaker) (London, UK)
17:40 - 18:45 Best performance EBEEM Part A & B certificate.
17:40 - 18:45 EMDM (European Master Disaster Medicine) Diploma ceremony. Pr Francesco DELLA CORTE (Speaker) (Novara, ITALY), Pr Ives HUBLOUE (Chair) (Brussels, BELGIUM)
FORUM HALL